external image TGSJ00006_m.jpg History of Health Care

Prior to the 17th century health care was provided by families, but following the turn of the century Sweden started small government and church associated care centers. In the 18th century the first hospitals were constructed and by that point care was segregated into rural and urban settings where "provincial doctors were responsible for large rural districts. At first these positions were financed by a combination of state and local funds.But in 1733, the national government took over the financial responsibility for the rural areas while urban physicians were paid from local town funds."

That is how the system ran until Sweden first looked to adopt a national health insurance program in 1946 with the passage of the National Health Insurance Act.The plan was not initiated until 1955, and it called for universal coverage for all citizens funded primarily by the government through local income tax revenue where the control of health care is primarily in the hands of the county governments in Sweden. "Doctors could still have a private practice, although by the 1960s about 80 percent of doctors worked in government-run hospitals."
Then reform was enacted in 1970, known as the seven crown reform, that called for doctors to become salary based employees of government run hospitals. "After the reform, most private health care in Sweden disappeared." Control was being taken out of the hands of the doctors, as government continued to enforce its control over health care in Sweden.

The Dagmar reform in 1984 decreased the powers of the doctors even further as they found it harder to work extra hours as private practitioners in their free time. The reform gave power to county councils to decide when and where doctors should work, so now the doctors were under control of county politicians. However, there were no incentives to control costs as budgets were flexible, where if more money was needed it was provided. The GDP graph on the Swedish financing page clearly demonstrates how costs rose during this time as a result.

As a result of increasing costs, Sweden needed to find a way to reduce spending. This posed a problem as the population was getting older and new technologies were being introduced. In 1982, when %GDP of health care spending was at 9.3%, and rising, the Swedish government enacted the Health and Medical Services Act. Fortunately, costs decreased as a result of the act. But to further control costs "The Dagmar Reform of 1985 changed the reimbursement formula to one of "capitation," in which hospitals and doctors were reimbursed for the number of patients served. This led to "global budgets" - a fixed amount that each county could spend annually on health care services."
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Despite the ability of the reform acts to control costs, quality of care was affected as rationing became a primary means of controlling costs . Waiting lists were becoming the biggest concern, especially for surgical procedures. A cause for the lack of quality care was a result of the poor leadership of politicians in control of the health care budget. "When asked about workplace problems, nurses cite the lack of leadership as the biggest concern, not the heavy workload. They see how budget cuts lead to the deteriorating quality of patient care. Politicians who know little about the actual situation in the hospital make cuts without realizing the consequences for the patients."

To deal with this growing issue over quality of care, Sweden in the 1990's developed a new model of health care, known as the "Stockholm Model." The model called for a move away from the more public run style of health care to a more market orientated system
. "The county council still provided the funding, but health care providers could be owned by private individuals or companies." This gave doctors and hospitals more control over the care of their patients and as a result quality improved. Costs also were maintained around 8.1% of the GDP.

The reform also gave patients freedom of choice over hospitals, which provided further incentives for doctors to increase efficiency and quality of care in attempts to attract more patients to their hospitals. And because hospitals and physicians were paid on a per case basis, the more patients meant more profit. To further promote patient choice the Patient Choice and Guarantee Act of 1992 was implemented which extended providers for patients outside of the country while guaranteeing that they be treated within three months of their diagnosis. Of the more significant results of this reform was waiting lists dropped by 20% from 1992 to 1993.

However, the initial successes of these reforms were short lived as waiting lists began to rise in 1994. By 1996 costs were on the rise. Rises in costs had multiple causes from multiple sources and they included:

  • County councils did not pay hospitals and physicians on a per case basis, which resulted in lower competition.
  • This lead to weak purchaser-provider relationship between counties and hospitals/physicians, which resulted in counties and hospitals reverting back to the older system, where government owned the hospital and provided funding. This also hurt competition.
  • The biggest problem, however, was that hospitals were not penalized or hurt if they could not attract patients, and city councils prevented them from shutting down.
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"One of the underpinnings of any successful market is that entities that do not adequately satisfy consumers eventually go out off business. The greatest failing of the market- oriented reform of the Swedish health care system is that they did not permit private providers to, in essence, "fail.""To keep these hospitals in business, greater funding was required, which in turn led to greater costs. As a result, by 2003, only about 50% of patients received care within three months of being diagnosed, breaking the guarantee of the now abandoned Patient Choice and Guarantee Act.

However, by 2005 with growing concern over wait lists, Sweden developed a new care guarantee similar to the one developed in the 1990's. The guarantee stated that "no patient should have to wait for more than three months once it has been determined what care is needed. If the time limit expires, the patient is offered care elsewhere, which is paid for by his or her own county council, including any travel costs." To this day waiting lists have been the ultimate problem for overall patient satisfaction with the Swedish health care system.

The graph below indicates the effects of waiting lists for patients in need of certain procedures in 2002 and 2003.
It can be seen how waiting lists problems increased from one year to the next. And despite the new guarantee in 2005, similar problems exist in the country to this day.

Figure 2: Percentage of Swedish Patients Who Received Treatment Within Three Months


Views on the Health Care System

Sweden's Health Care System is not the most highly praised system, primarily resulting from the long waiting lists and the rationing of care that results from their single payer system. Alongside issues over waiting lists and rationing, problems with government involvement in medical decision from both patient and provider were a issues of high concern. Although the privatization of health care providers was developed to address these issues, problems are persisting leaving many in Sweden dissatisfied with their health care system.

A recent study was done on patients attitude toward priority setting (rationing) in Sweden's health care system, and here are its primary findings.

  • The majority of people were against rationing and believed they deserved unlimited access to medical care regardless of cost.
  • Only 6% were for a priority oriented system where younger individuals were more accepting of a priority based system compared to older individuals.
  • More importantly if prioritization was necessary the majority (73%) believed that it should be left in the hands of health care professionals instead of government who had a support from 5% of individuals surveyed.
  • Interestingly enough " Nearly one in 10 had experienced some kind of rationing and among these patients a majority were satisfied with the outcome of that day’s contact."

Public opinion is thus relatively in agreement on their attitudes towards the health care system, where they disagree with a priority system, yet if it is necessary, they would prefer decisions were left in the hands of medical staff. A second study on medical students had similar results stating "A larger proportion of respondents were more favorable to physicians and other health personnel being responsible for rationing decisions as opposed to politicians."

Although it appears as though the majority are satisfied with their care despite rationing procedures, it still leaves out the opinions of those left waiting for procedures that are vital to their quality of life. According to the nationalcenter.org, effects of long waiting lists include:
  • loss of dignity, powerlessness, and frustration
  • loss of ability to do everyday activities
  • depression and hopelessness
  • pain and anxiety
  • sometimes death
The greatest problem is that patients often require outpatient care as a result of being stuck on the waiting list and end up costing more than would the actual procedure. "One study that examined over 1,400 Swedes on a waiting list for cataract surgery found that 5.2 million kronas were spent on hospital stays and home health care for patients waiting for surgery. That was the equivalent of what it would have cost to give 800 patients cataract surgery."

Another issue among patients is that there is little to no relationship between doctors and patients. "The impersonal nature of the system has caused some discontent in Sweden." It may be a result of the issue over rationing where doctors do not have the time to fully develop a communicative relationship with their patients.

Below is a link to tables indicating the quality of care received by male patients of various ages on a scale of four compared to other countries. Of the most important results from these tables, for one, was the patients' ability to participate in the decisions that applied to their care. The mean rating was about a three out of four, much lower than other countries in the table as well as in regards to other questions asked. Another important piece of information from these tables was from table 2 which wondered whether patients received important information on the care their doctor was responsible for. The average rating again was close to a three,significantly lower than other countries and categories of the survey. Both results indicate a lower level of patient doctor communication.
Ratings of Health System

However, despite the many issues that arise from Sweden's single payer system that calls for equal access for health care (which is a nice way to phrase rationing care), government, particularly the left, looks to maintain the status quo if not gain support for the current system. For example, Prime Minister Persson of Sweden, despite his position in government, opted to place himself on the waiting list for a hip surgery he required. From a central/right political standpoint, their primary concern is over the freedom of choice of the patient to choose the provider they believe best fit.

For doctors, the biggest concern is control over the care they are able to provide. Whether it be the fact that decision making is left in the hands of local councils or because of budgeting problems, the result is the same; doctors are often restricted on care they can provide even to those who may need it. Another problem for doctors, according to Dr. Olle Stendahl is "In our budget-government health care there is no room for curious, young physicians and other professionals to challenge established views. New knowledge is not attractive but typically considered a problem (that brings) increased costs and disturbances in today's slimmed-down health care."

Despite the varying opinions and ideas about Sweden's health care system and its need for further reform, the system's organization
may hold key insights for the United States in its pursuit of health care reform.