sou · H7B342 · 2019-10-01 00:00:00 — In addition, it is emphasised that the overall purpose is to safeguard the possibilities for equitable care, given the existing division of responsibilities for health care. specifically, the Inquiry is to review the patient choice systems and, in accordance with trust-based governance, consider which management systems best promote objectives fulfilment, including the need for changes to payment models. Supplementary terms of reference task the Inquiry with analysing how a long-term sustain- able system for ‘Online Doctors’ (providers that mainly offer digital health services – so called digital health service providers) can be created. The Inquiry is also to survey the use of temporary employees in health care and present proposals for how a more continuity-based health care system can be promoted by reducing the use of tempor- ary staff, and consider the advantages and disadvantages of introduc- ing a permit requirement to conduct health care. The Inquiry has described in an interim report the differences in health care consumption by patient groups with different socio- economic backgrounds and starting points for better governance (SOU 2018:55). The Inquiry’s work has been conducted very openly and a lot of time has been invested in listening to the thoughts and ideas of various stakeholders at meetings and hearings. The patient choice scheme needs to become digi-physical A central issue in the Inquiry’s task is the fulfilment of objectives under the Health and Act and in particular the objectives regarding health care on equal terms for the whole population and that those with the greatest need of health care must be given priority. Strengthening the conditions for objective attain- ment has permeated the Inquiry’s work. The review of the patient choice system and the analysis of the digital health service providers has meant that the Inquiry’s work has primarily been focused on primary care. We support the assessment made by several other inquiries that the health care system needs to be reorganised in a way that ensures primary care has adequate resources. The starting point for the Inquiry’s analysis is that a number of components are particularly important in this reorganisation: •The patient and citizen perspective needs to be strengthened, with a more person-centred care that is to a greater extent based on the different needs of individual people. •Continuity needs to pervade the governance and organization of health care, as this will help increase patient safety and efficiency. Continuity also increases citizens’ confidence in the health care system. •Transparency and long-term thinking in the system need to be increased, with greater clarity regarding what patients can expect from health care and what obligations providers have. •The digital revolution needs to have a broad impact on health care and become a more integrated part of all health care. •A more national system is required, with fewer differences in governance between the county councils. •System efficiency needs to be increased throughout the public- financed health care system. A key aspect is strengthening the resources and competence in primary care. The Inquiry’s analysis shows shortcomings in the care choice system The care choice reform was implemented in 2010. The core of this reform was the regulation of a mandatory ‘patient choice system’ in every county council. The regulation dictates that each county council has to organise primary care, so that the patient has freedom of choice between all of the providers in primary care, and that any private provider who meets the requirements set by the county council have the right of . In accordance with its remit, the Inquiry has conducted a review of the patient choice systems in primary care, as well as the ‘care in another county’ regime and the emergence of digital health service providers. All three aspects are closely linked and the work of the Inquiry has dealt with these aspects in an integrated . The Inquiry’s analysis has shown, for instance, that a basic pro- blem is the undercapacity in primary care, which makes it difficult for the patient choice systems to function. The patient choice reform has only to a small degree contributed to a more equal and needs-based care. The current regulation and implementation in some areas entail difficulties in improving objective attainment. The way the choice of primary care provider is designed in differs from other countries, in that by law the choice is made through contact or visit (consumption of care) and not in advance (for instance, by being registered with a provider). However, the wording of the act and the governance of the county councils pull in different directions and create a tension between demand-driven and needs-driven care. The conditions for continuity, efficiency and a good working environment are negatively affected by this. Information to citizens is inadequate with regard to accessibility and continuity. There is a need for increased governance of primary care pro- viders within the patient choice system, and for increased gover- nance of in primary care. Application of the law often leaves no scope for primary care providers to limit the number of patients per provider or per profession. is there any regulation of the number of re-registrations with providers. Combined with the shortage of resources in primary care and other elements in the governance, the effect is that providers have difficulty planning their activities, which can in turn entail risks for patient safety, poor accessibility and an untenable working environment for the pro- fessionals. The adoption of the Patients Act in 2015 extended patients’ free- dom of choice regarding outpatient care to cover all county councils. This further reduced the scope for care providers to plan their actions. Current governance, including the payment system, is inadequate. The lacking coordination, the frequent changes in contracts and payments and a high level of detail, does not signal trust. This makes it difficult for primary care providers to plan long-term and various distorting incentives in the governance entail risks with regard to needs-based care, particularly with regard to care in other counties. Governance differs between the responsible authorities, while parts of the system are becoming more national. The Inquiry con- siders that there is a need for a more national system, but with the opportunity for local adjustments. Specific comments on digital health service providers The so-called ’Online doctors’ development of digital tools and working methods has entailed an innovation with the potential to be a major asset to patients, the profession and the efficiency of the system. Digitalization creates the opportunity to remedy one of the main problems of primary care – accessibility – e.g. by being independent of geography and enabling asynchronous contacts. Digital working methods create better conditions for giving professionals greater flexibility in their work which is very valuable to the attractiveness of the caring professions. With the current system, the digital health service providers come into the system via the external county reimbursement, which has caused a clash between a decentralised patient choice system and a national system for digital care. The county council’s special pay- ment system for digital care in another county (higher fee-for- service when the patient resides in another county) is not provided on equal terms for providers with contracts and sub-contractors. This is not sustainable in the long run for many different reasons. The Inquiry considers that a special national system or a new level within primary care should not be proposed for the digital health The major challenge for health care in attaining efficiency and patient centeredness is to achieve smoothly-functioning coopera- tion and coordination. Dividing the primary care remit in this situa- tion into a separate digital system (including digital health service providers) that is managed by certain care providers, and other care that is managed by other providers, will be counterproductive. The divide should not be made according to the choice of technology or working method. The type of simple need that the digital health service providers have so far usually dealt with are not always re- solved entirely online – primary care therefore needs to improve its accessibility for simple care needs that require physical care. The conditions for health care providers and patients’ access to health care are poorer in sparsely populated areas The conditions for providing care in sparsely populated areas are often particularly challenging. It is often more difficult to recruit staff, which results in a greater dependency on temporary staff. At the same time, some county councils with a lot of sparsely populated areas contribute a lot to training staff as they know that many of them will then move away. The conditions for providers in the patient choice system are often poorer, partly because there is a smaller potential patient base, while the remit may be more demanding. Primary care centres in sparsely populated areas often run at a loss, too. When the patient choice reform was introduced, no analysis was made regarding care in sparsely populated areas, despite these areas being unevenly distributed between county councils and despite the fact that it should be an obvious conclusion that it is more difficult to find ‘market-like’ conditions for providing care in areas where there are few residents. A proposal is being drafted regarding reforming the local govern- ment equalisation system, where sparsely populated areas play a role, but as the entire primary care system is underfinanced, it is doubtful that this measure will be sufficient. The Inquiry presents some pro- posals in this field, but mostly envisages that the question must be managed within the framework of a broader focus, where the role and responsibilities of the state are clear and where a stance is taken on welfare as a whole and its long-term funding and presence in sparsely populated areas. Proposal for an integrated digi-physical choice reform The Inquiry puts forward a number of proposals and makes recom- mendations to the county councils. Overall this reform package is termed an integrated digi-physical choice reform. These proposals also take into account how governance is conducted in other countries with patient choice, such as and , while also safe- guarding the unique and well-functioning parts of the Swedish system. This shift towards continuity as the starting point for patient choice and organization of services, will be an important part in the change- over to a strengthened primary care. New basis for patient choice in primary care The Inquiry puts forward a number of proposals to bring the patient choice system more in line with other choice systems and with patient choice systems in other countries. This increases the pro- spects for giving the patient choice value for the patient. •The concept of registration with a care provider is used con- sistently by the county councils but does not exist as a concept in the current legislation. The Inquiry proposes that the concept of registration is introduced into the legislation and forms the basis for the patient’s choice of primary care provider. Registration aims to ensure that citizens and patients choose their care provider in advance. The proposal entails a codification of the way that the county council already works in administering the patient choice systems and can also be compared with other such systems, and with patient choice systems in other countries. •The choice of primary care provider in another county council is proposed to be made via registration. The current possibility of consumption of primary care in another county in the form of temporary visits to a primary care provider other than the one where the patient is registered will be limited by this proposal. •The Inquiry proposes that registration take place at provider level, that is, at a primary care centre or equivalent. The Inquiry assesses that this will give sufficient flexibility for diversified care and it is the solution that best takes into account the strengths of today’s primary care system in – multiprofessionalism and team work. The primary care provider is also the legal con- tracting party, which is something that distinguishes from many other countries that have registration with doctors and where the doctor is the contracting party. •The current regulation in the Act on System of Choice in the Public Sector (LOV) that the county council must supply a non- choice alternative for those who are not willing or able to make a choice will be retained. The basis for the non-choice alternative should be the principle of proximity. Clearer requirements for primary care providers The Inquiry considers that changes are needed to the requirements made of care providers, to make care more accessible and integrated. •In the Inquiry’s assessment, it is important to create personal continuity by the patient being connected to a named doctor and preferably a named care team. It is recommended that county councils set requirements regarding continuity and give patients the opportunity to choose. •The Inquiry proposes that choice through registration can only take place with providers of primary care services that are ac- credited according to the Act on System of Choice in the Public Sector (LOV) or have the corresponding contract according to the Public Procurement Act. •Primary care offered by sub-contractors to a care provider should still be offered to patients within the framework of the care pro- vider’s remit. •It is recommended that the county councils require that all primary care providers ensure both digital and physical accessibil- ity (digi-physical care). The county councils need to state clearly in the contract documents for the patient choice system which specific requirements are made of care providers with regard to both digital and physical accessibility. Primary care providers’ obligations must be made clearer to the patient Several of the Inquiry’s proposals and recommendations aims to clarify for the patient the advantages of turning to the same care provider. •The information given to patients should be reinforced with regard to what choices the patient has, accessibility, how to make the choice and in general what the patient can expect from the primary care system. •It is also recommended that the duty to provide information is reinforced for patients who do not make an choice and are therefore passively registered at a non-choice alternative. •It is recommended that the county councils apply different fees for patients visiting their chosen care provider as opposed to when they visit another provider. The patient’s fee should be lower at the provider where they are registered. •The Inquiry proposes that the health care guarantee in primary care apply at the patient’s chosen primary care provider. The health care guarantee for registered patients should in the long run be further strengthened. Plannable operations for primary care providers The Inquiry considers that some changes in the patient choice system are necessary to create better conditions for patient safety, planning and a good working environment. •The Inquiry proposes that the county councils should be allowed to decide to limit the number of patients that can register with a primary care provider, after consultation between the county council and the provider. A primary care provider must have reasonable conditions for planning so as to conduct operations of high quality and with good patient safety, and this may entail having to limit the number of patients registered. •The county council has an obligation, on the basis of its overall responsibility for planning, to ensure that primary care has re- sources to support an adequate number of providers that meet needs of the population. •The Inquiry proposes that patients should be able to re-register twice a year, within the scope of the reformed patient choice system, unless there are reasons otherwise. This proposal will provide increased patient safety and efficiency. A more national system with the possibility for local adaptations The Inquiry considers that action is needed to attain greater national equality and increase transparency in the patient choice system. •The Inquiry proposes a nationally-regulated patient fee in the patient choice systems in primary care, with the same appoint- ment fee in all county councils. The fee should be . •The Inquiry proposes that the county councils offer a registra- tion service. This service will enable patients to make their choice of care provider and receive information on all providers they are able to register with and the provider’s availability for registra- tion. It is recommended that the county councils take joint responsibility for making the registration service part of a national portal that contains more patient choice information aimed at the patient. The county councils should jointly work on this question. •The Inquiry recommends that the county councils agree on a national marketing and information policy that is aimed at care providers who receive public funding to provide care. •The Inquiry’s assessment is that competitive neutrality will be positively affected by a more national system. However, several questions require further investigation. •The Inquiry recommends that the county councils continue to focus on dialogue-based follow-up of care providers. •The Inquiry recommends that, in connection with the intro- duction of a nationally-regulated basic remit, the county councils also apply common payment principles for primary care. The following principles should apply: long-term approach, stability and innovation-promotion, annual adjustment of payment, fixed payment (capitation) for registered patients as main payment, risk adjustment in capitation to steer towards those with the greatest need, less micro-management, continuity and accessibil- ity are prioritised and rewarded, make service and phar- maceuticals a ‘free utility’ for providers of primary care to a greater extent. The county councils should avoid treating care providers differently, distorting incentives and treating different forms of contact differently (such as visits to a care provider other than the one where the patient is registered or within another county). •The Government should follow developments in the field. If the principles are not applied after two years, further measures should be considered, in the form of regulation of the principles. •The Inquiry recommends that the county councils initiate a fundamental review of the national contract for outpatient pay- ment. This review should include an assessment of special measures for areas with periodically large burdens from other counties, such as Åre and . •The Inquiry recommends that the county councils jointly, and together with the central government, investigate the future design and function of 1177. Governance of localisation of primary care centres Increased governance can enable the county councils to ensure more needs-based and equitable of providers. •The Inquiry proposes a clarification in the legislation regarding the possibility to divide the patient choice system in one county council into different geographical areas. The Inquiry’s assess- ment is that this should be done to clearly and transparently create opportunities for other assignments in advance in sparsely populated or other types of areas. The proposal does not limit patient choice. •In addition, the county councils are recommended to increas- ingly adjust the payment system to make it more attractive for providers to establish primary care centres in certain areas. This is done by all county councils today and the Inquiry recommends that the county councils use this to an increased extent. The county councils should also agree on principles for this governance to create increased uniformity and transparency in governance. •The Inquiry recommends that the county councils use the opportunity to supplement accreditation according to the Act on System of Choice in the Public Sector with procurement pur- suant to the Public Procurement Act and in those cases offer more advantageous terms for places where not enough providers establish primary care services. What does the proposal entail for today’s digital health service providers? The Inquiry´s proposals are aimed at creating an integrated digi- physical patient choice, where the patient can turn to the same primary care provider regardless of whether they do so digitally or via an appointment. This will have consequences for providers who today operate within the patient choice system in another county regime, primarily the digital health service providers. •Today’s digital health service providers may need to apply for in all county council areas under the Inquiry’s pro- posal. These providers would need to offer in-person health care, either themselves or by using sub-contractors. After , patients can register with the primary care provider, who will then have access to the capitation that follows from registration. The capitation would also contribute to the patient’s physical care. •These companies may also be hired as digital care sub-contractors by primary care providers who currently supply mainly tradi- tional primary care with in-person appointments. In these cases the company in question can sign an agreement with the main supplier – an agreement that also regulates the financial payment. •The current possibility for a sub-contractor to a primary care centre in one county council area to offer appointments nation- ally reimbursed as fee-for-service will not be retained. The Inquiry does not propose a national permit requirement The Inquiry has considered the advantages and disadvantages of a national permit requirement and has analysed which areas would be appropriate for this kind of requirement. The conclusion is that there is no reason at present to introduce any form of permit requirement in health care, apart from the situations that are already regulated. •The Inquiry proposes that the for Public Procurement is tasked with analysing the need for updated na- tional guidance for examination and requirements pursuant to the Act on System of Choice in the Public Sector and the Public Procurement Act, and if necessary produce an updated version. The guidance document is aimed at the responsible entities in health care. •The Inquiry recommends a further investigation into the condi- tions for a national register of health care providers that have taken part in a procurement process within health care. Measures to reduce dependence on temporary staff The Inquiry has, in accordance with its remit, surveyed the use of temporary staff. The cost of using temporary staff instead of own staff is currently around 4 per cent of the total costs for employment (SKL 2018), with a variation between county councils of 2–14 per cent. County councils with extensive sparsely populated areas have consistently higher levels. The cost of temporary nurses is currently increasing at a much faster rate than the cost of physicians. How- ever, the statistics reported do not state the estimated additional cost for temporary staff, only the actual cost. Of course, staff entail a cost regardless of whether they are temporary or employed. Based on the calculations made in region, it can be estimated that the additional cost for having temporary staff is around 40 per cent of the actual cost.