sou · GRB323d1 · 2004-01-01 00:00:00 — One important differ- ence of principle between the publicly operated care and the private contractors are that the administratively operated health care takes part in the full responsibility that rests on the county council or the municipality as the responsible authority. The extent of the undertaking of the private contractor is based on a voluntary agreement and limited to what is in the contract. If the county councils as clients fail to include obligations in the agreement that can arise in extreme situations, disasters, major accidents, etc., the task of maintaining a readiness for extraordinary efforts will be greater on the publicly operated parts of the health care system. The greater the part that is contracted out, the more marked this difference in conditions will be. For similar reasons, the demands for flexibility and adaptation to new economic conditions or care requirements create differences in conditions. The contract between a private care provider and a county council extends as a rule over a number of years and speci- fies in various ways the volumes and the financial prerequisites for the activity. If the care requirements change quickly in relation to the forecast and agreements or county council finances require swift adaptation and savings, the private entrepreneur can be protected by contract from changes while the entire burden of adaptation falls on in-house organizations. In this case as well, the differences in the conditions increase the greater the proportion of care contracted out unless the client has foreseen the need in the contracts to apportion the demands for flexibility and adaptation among all care providers. No recommendations have been made on a regulatory frame- work in these respects although the commission considers that these are questions that should be taken into consideration when contracts are entered into. An unavoidable difference until further notice is that that arises in procurement. Private care providers are, like the rest of the busi- ness sector, free to develop long-term commercial relationships and partnerships with, for instance, suppliers of services or techni- cal equipment. The public care providers whose operations take place in an administrative form or as municipal enterprises have to comply with the procurement legislation, however. This may lead to additional administrative work and poorer conditions for long- term development co-operation with different suppliers. Different rules for financing However, in present conditions, the crucial difference between publicly operated health care and private care providers is that the private care providers, unless otherwise agreed, often have the right to accept patients who pay privately. The main reason for paying for care privately, directly or through private health insurance, is a to obtain health care through another priority than that that applies to health care otherwise. Privately financed health care is therefore a problem, in the sense that it will clash with the basic principles for health care; i.e. health distributed according to need and on equal terms. Private financing of health care is instead based on peoples position as an actor. The possibility of privately financed health care is linked with financial status, attractiveness on the labour market or otherwise, and not to the person as a person and her needs. There is a very strong consensus in on the concept of social and care on equal conditions. It would therefore be a very unfortunate consequence if more private contracts in publicly financed health care, with the advantages that this otherwise entails, led to the Swedish health care system segregated according to finances or social class or otherwise. The same rules for financing The hospitals, clinics and other institutions that the county coun- cils have built up are strong symbols for the communitys common assumption of responsibility for health care. It is important that they, even if responsibility is transferred to a private care provider, retain an identity of this kind. The regulatory framework aims at creating equivalent conditions for financing and that patients receive similar opportunities for health care regardless of whether the responsible authority operates the activity in its own auspices or it is contracted out. Private entrepreneurship means a time-limited commission. When the agreement expires, a new procurement process is to take place. The possibility of an equivalent procurement will be consid- erably poorer or even impossible if the private contractor has, within the framework of the activity during the period of contract, also developed activities with health care to other groups of patients according to contracts which it exercises control over itself. Mixed financing can create incorrect incentives in the health care system. Queues and long waiting times for publicly financed health care can contribute to new large incomes for care of patients with private financing. The risks of such distorted incentives will be reduced if the purely private health care can be kept organization- ally clearly separate from publicly financed health care. The commission recommends for other hospital care and specialist health care a regulatory framework that as regards the opportunity for receiving compensation from private patients creates uniform conditions for publicly operated health care and for private entrepreneurs, who engage in health care activities that have been built up or initiated by a county council. The task of being responsible for operation of health care activities established by the county council may only be transferred to those who contractually undertake, within the framework of the activity, to exclusively provide health care financed by the county council, municipality, or a foreign legal entity with a corresponding task. The commission also underlines the importance of the forms of compensation. For publicly financed health care, whose care responsibility includes everyone, it is important that forms of compensation promote public health inputs and preventive health care. Time and resources should be available for contact and collaboration with schools, social services, and other bodies that can contribute to preventing injuries and ill health. For this reason, a larger or smaller part of the compensation is provided in many contracts in some form of capitation allowance. The care provider is compensated for a broader care responsibility for a particular population, listed patients or otherwise. Compensation for patient appointments will be correspondingly less. In the case of privately financed patients, the whole compensa- tion is as a rule associated with the visit to the doctor or the treat- ment. Viewed as marginal income, the private patient will there- fore be more profitable in an additional way, with the conse- quences that that can be thought to entail for accessibility and how they are dealt with. The consequences will be similar for a hospital with appropria- tion financing and care responsibility for the population. When hospitals are compensated per treatment (Diagnosis group related compensation or similar), the differences were less, although the system of compensation has other disadvantages. The marginal cost of the care provider for an additional patient is low when equipment and staff already exist. For the client and the patient with public financing, the agreed compensation is based on an aver- age of the care providers total costs. It is important for the performance-based systems to find forms of compensation that better reflect the relationship between fixed costs and marginal costs. There is strong support among the Swedish public that health care should be provided on equal conditions and be made available on the basis of need. A clear majority also wishes to retain hospitals in public ownership. At the same time, there is a need, weighed in relation to the challenges that will confront health care, to stimulate development and renewal by alternative forms of operation. The value of the private contracts as a reference and sometimes as examples for publicly run activities will be less if another mix of public and privately financed care is permitted than what is possible when health care is operated directly by the council councils and municipalities. The mix, based on a right to faster treatment, is also in strong conflict with public opinion. Other care providers can provide private and publicly financed care It is, however, neither possible nor desirable to exclude opportunities for privately financed health care. This possibility has existed for a long time in . Should the opportunities for privately financed health care be restricted, there are equivalent opportunities for health care in other countries to an increased extent. Privately financed health care has been available for a long time at, for instance, hospitals such as Sophiahemmet in or Hospital in . Doctors in private practice have been able to have private patients as well as providing health care for county council patients. A fairly large number of clinics for various specialties such as eye surgery, orthopedics, heart operations, and fertility treatment have been built up as independent units in recent years. Through agree- ments with the county councils, they can accept publicly financed patients, but also patients with private health insurance and those who pay with their own money. The difference between these private care providers and the private entrepreneurs, who contract to run activities that have been built up or initiated by county councils or municipalities, is that they have established the activity themselves, arranged the basic financing and taken greater risks. Their relationship to the county council or municipality is also different. They have full control of their investments, organization and staff resources. They can never run the risk of another contractor taking over the activity after the procurement process. Their activity is more on market terms. The owner retains the activity as long as it is of such quality and has such costs that they receive enough commissions through contracts and patients own choice. They stand for continuity in a health care system where con- tractual solutions risk in resulting in uncertainty due to recurrent changes of management and operational responsibility. It would not be desirable for the state to legislate to prevent these care pro- viders offering health care to others, alongside of contracts on publicly financed health care or for county councils to do so by contract. Recent experience shows how these more or less genuine contractors in health care have established activities in fields where it is problems in the form of long waiting times. In many cases, the contractors have met the needs with new and more cost-effective forms of treatment. Viewed from this aspect, it should be an advantage, if the rights to provide private-financed health care is restricted to these care providers. It is also a matter of fair competition. The conditions are not equivalent if private contractors, who are contracted to run activity that the county council or municipality have originally developed, can offer corresponding services on the to the privately financed health care market. The issues of how needs are to be defined is also part of this discussion. The wording in the Health and Act is that those who have the greatest need of health care should be given priority to care. The assessment of needs is and should be, more far reaching than an exclusively view. Social situation or the number of dependents is as a rule regularly included in the assessment and priority of needs made by health care. However, it is probable that the assessment made by public health care does not always coincide with that made by enterprises and organizations of the key roles of different people and where a persons of obtaining health care can affect many others. The health care system needs safety valves, which make possible privately financed health care, on the basis of this type of consideration as well. What is at stake is to find a balance between this need and the risk of development into a two-tier health care system. Health care and no fast tracks The temporary legislation that applied until the end of 2002 prohibited transfer of acute hospitals to private for-profit owners. The blocking legislation was introduced to provide a breathing space for discussion on the conditions on which private care providers were to be able to operate in the health care system. A strong motive for the introduction of the blocking legislation was to prevent the publicly owned hospitals being opened up to a two- track health system through privatization and the absence of regu- lation. However, preferential treatment does not only occur at the entrance to the hospital. Opportunities for faster treatment and initiatives that depart from the order of priorities can arise in many parts of a care chain. A newly presented Canadian study points to the lack of capacity for different forms of diagnosis as an important factor in uneven distribution of health care resources. Those who have their own financing can shorten the waiting time for diagnosis and also receive faster treatment. The same situation applies here, in the view of the commission of inquiry. If a patient, through private financing, obtains a faster diagnosis at, for instance, a private clinic, this can also lead to faster treatment. The legislature proposals of the commission for a barrier against privately financed health care includes private contracts for hospi- tals that have been established by county councils and also corre- sponding private contracts for community health care, specialist clinics and other health cares established by the county council. Primary care, however, is not covered by these regulations. It is not within the Commissions task (an example of a corresponding regulation for the primary care is presented in an appendix). The assessments made by the commission argue, however, strongly for the regulation proposed by the commission also being extended to primary care. In the case of primary care as well, preferential treatment to a privately financed patient can provide faster access to the contin- ued publicly financed care chain in a way that does not correspond to the order of priority. It is also difficult to draw a border between primary care and, for instance, off-patient specialist hospital care. The ambition should instead be to integrate primary care and other care as far as possi- ble. This is also what is happening with concepts such as commu- nity health care and by the participation of specialists in primary care. An additional reason is the forms of payment. The care provider receives the whole payment for a visit from a private patient. The county councils payment for primary care is based, with the exception of charge-based doctors, on a larger or smaller propor- tion of capitation payment based on listing or responsibility for a particular population. In many cases, but not all, the county councils have introduced a prohibition against private financing in contracts with private entrepreneurs in primary care with the corresponding content as the commissions proposals. There are strong reasons for continuing to closely observe and investigate developments in primary care. This partly concerns general access but also the extent to which private contractors in primary care gives patients with private financing faster access to health care and the chains of care. Conditions for not-for-profit organizations and small enterprises should be improved The legislative proposals that the commission has put forward do not relate to hospitals as a concept and do not either distinguish between private for profit and not-for-profit health care in the proposed statutory arrangements. The Riksdag has with broad support adopted a national action plan that strongly emphasizes the value of diversity. The broad political consensus on the action plan is of great value. The plan underlines the value of new undertakings, cooperative, idea-based organizations, private undertakings, etc. having the opportunity to take part in health care. The commission discusses in a separate section how the condi- tions for not-for-profit organizations and small-sized enterprises can be improved. lag om ändring i hälso- sjukvårdslagen (1982:763) Härigenom föreskrivs i fråga om hälso- och sjukvårdslagen (1982:763) dels att 3 § skall ska ha följande lydelse, dels att det i lagen skall införas två nya bestämmelser, 9 a och 9 b §§, av följande lydelse. Varje landsting skall erbjuda en god hälso- och sjukvård åt dem som är bosatta inom . Detsamma gäller dem som är kvarskrivna enligt 16 § folkbokföringslagen (1991:481) och stadig- varande vistas inomlandstinget. Även i övrigt skall verka för en god hälsa hos hela befolkningen. Vad som i denna lag sägs om landsting gäller också kommuner som inte ingår i ett landsting, i den mån inte annat följer av 17 §. Vad här sagts utgör inte hinder för annan att bedriva hälso- och sjukvård. ansvar omfattar dock inte sådan hälso- och sjuk- vård som en kommun inom har ansvar för enligt 18 § första och tredje styckena. Ett landsting får sluta avtal med någon annan om att utföra de uppgifter som ansvarar för enligt denna lag. En uppgift som innefattar myndig- hetsutövning får dock inte med stöd av denna bestämmelse över- 1 Senaste lydelse 2002:1028. lämnas till ett bolag, en förening, en samfällighet, en stiftelse eller en enskild individ. får även träffa överenskommelse med kommun, den allmänna och länsarbetsnämnden om att inom ramen för upp- gifter enligt denna lag samverka i syfte att uppnå en effektivare användning av tillgängliga resur- ser. skall bidra till finansieringen av sådan verk- samhet som bedrivs i samverkan. får granska sådan verksamhet som bedrivits i samverkan med och delvis finan- sierats av eller länsarbetsnämnden. Vid en sådan granskning har rätt att ta del av de uppgifter som behövs för att granska verksam- heten. Ett landsting får sluta avtal med någon annan om att utföra de uppgifter som ansvarar för enligt denna lag. En uppgift som innefattar myndig- hetsutövning får dock inte med stöd av denna bestämmelse över- lämnas till ett bolag, en förening, en samfällighet, en stiftelse eller en enskild individ. får även träffa överenskommelse med kommun, den allmänna och länsarbetsnämnden om att inom ramen för upp- gifter enligt denna lag samverka i syfte att uppnå en effektivare användning av tillgängliga resur- ser. skall bidra till finansieringen av sådan verk- samhet som bedrivs i samverkan. får granska sådan verksamhet som bedrivits i samverkan med och delvis finan- sierats av eller länsarbetsnämnden. Vid en sådan granskning har rätt att ta del av de uppgifter som behövs för att granska verksam- heten. Uppgiften att ansvara för drif- ten av hälso- och sjukvårdsverk- samhet som etablerats av lands- ting får endast överlämnas till den som i avtal förbinder sig att inom ramen för verksamheten uteslutande ge vård som finansi- eras av landsting, kommun eller utländskt rättssubjekt med mot- svarande uppdrag. Vad som sägs i första stycket gäller inte när uppgiften att ansvara för driften av primärvård överlämnas. Uppgiften att ansvara för drif- ten av hälso- och sjukvårdsverk- samhet som samordnas inom eller mellan sjukvårdsregioner får dock inte överlämnas till någon annan än som avses i 3 kap 17 § kommunallagen (1991:900). På avtal som ingås före ikraftträdandet tillämpas inte 9 b §. 1 Vårdsystem i omvandling Utredningens uppdrag är att lämna förslag som för ett vårdsystem med ökad mångfald av drifts- och ägarformer kan säkerställa de grundläggande målen för svensk hälso- och sjukvård; vård på lika villkor, fördelad efter behov. I sin diskussion av möjliga modeller för reglering och med stöd av förslag, idéer, kritik och synpunkter från yttranden över idébe- tänkandet Vinst för vården (SOU 2002:31) har utredningen sökt att väga in hur en reglering kan påverka vårdens vägval och struktur: hur stärks förebyggande vård, hur utvecklas ansvarskedjor och samhörighet, hur stärks mer patientnära vård och hur kan solidari- tet i ett gemensamt vårdsystem bevaras och utvecklas? Privata aktörer, marknadsinslag och vinstintresse finns inom den svenska hälso- och sjukvården. Det finns delmark- nader för läkemedel, teknisk utrustning, byggnader och en arbets- marknad för personal. I de senaste årtiondenas utveckling tillkommer två trender. Den offentligt drivna vården har genom rolldelning beställare-utförare eller genom andra former för ersättningar och avtal infört mer marknadslika styrformer. Efterhand har också successivt fler delar av hälso- och sjukvården öppnats för privata entreprenörer och alternativa driftsformer. I det två inledande avsnitten söker vi att från olika utgångs- punkter belysa vilka möjligheter och problem som kan vara förenade med ökade inslag av privata drifts- och ägarformer inom vård och omsorg. Frågor om privata entreprenörer med vinstsyfte och deras roll inom hälso- och sjukvården (och andra välfärdstjänster) har varit och är kontroversiella i men också i andra länder. WHO Europakontor summerar sina intryck av den europeiska debatten så här: Proponents, trumpeting the benefits of privatization, put it forward as a magic pill that will cure all the ills of the health care system. Opponents vilify privatization and associate it with personal greed and the end of social solidarity. (WHO Regional Committée for Europe, ) Medan förespråkarna lanserar privatisering som ett magiskt piller, som kan lösa alla hälso- och sjukvårdens problem, kopplar motståndarna privatiseringen tätt samman med personlig girighet och avvecklad solidaritet. Bristen på underlag för analys, en diskussion med i huvudsak ideologiska argument och oviljan att ta del av andra bedömningar gör positionerna låsta. Det gäller också i . Men om vårdorganisationen skall kunna utvecklas för att klara växande anspråk behövs stabilitet och mer långsiktiga spelregler. Det gäller besluten om inriktning av landstingens verksamhet men också besluten på nationell nivå. Politisk samsyn eller i andra hand en accepterad kompromiss är ett villkor för att lagstiftning eller annan reglering skall ge varaktiga spelregler över tiden för dem som verkar och vill verka inom vårdsektorn. Nya möjligheter – växande anspråk Den medicinsk-teknologiska utvecklingen förbättrar oavbrutet möjligheterna till diagnostik, behandling och bot. Vårdens metoder blir effektivare och mer verksamma och behandlingstider blir i många fall kortare. För många sjukdomsfall har möjligheterna till överlevnad ökat avsevärt. Men människan är inte odödlig och den behandling som gav fortsatt liv kommer förr eller senare att följas av ny behandling, annan sjukdom eller svaghet. I den meningen belastas vården alltid av sina egna framsteg. Ökad medellivslängd och effekten av tidigare variationer i födel- setal leder under dessutom till att andelen äldre och därför mer vårdbehövande i befolkningen blir större. Det gäller i och i många länder i . Trängda mellan ekonomins begränsningar och de växande vård- behoven söker politiker, vårdpersonal och administratörer i alla länder efter lösningar. Förhållanden, tradition och organisations- former varierar men de grundläggande problemen är likartade. Det är svårt att få fram finansiella och personella resurser för att klara behoven av vårdinsatser. Oberoende av vilket vårdsystem de har, söker länder efter andra organisatoriska och administrativa lösningar och nya former för finansiering, drift eller ägande. Frågor om drifts- och ägarformer finns i fokus även för denna utredning.