Marketisation of Swedish Primary Care : Patient Choice, Provider Competition and Payment Incentives

Sammanfattning: In the last decades, market elements—such as patient choice, provider competition and payment incentives—have been introduced in Swedish primary care, the Patient Choice reform in 2010 being pivotal for the marketisation of the sector. The political intentions with the reform were to empower patients and increase provider diversity, thereby stimulating competition and improving quality and access. The reform embedded a more market-based governance of the sector; resource allocation and accountability being achieved on the basis of patient choices, and policy goals being attained through provider competition. For this to occur, several conditions on both the demand-side and supply-side must be fulfilled. Empirical evidence on market conditions are, however, especially lacking on the supply-side. The aim of this dissertation is therefore to investigate whether and how the Swedish primary care sector and its providers have adapted to the market elements of the Patient Choice reform. Three research questions are raised, addressing how providers perceive and respond to the different market elements, how competitive the sector is, and in what way the market elements promote achievement of central policy goals: quality, access and equity. To answer these questions, four studies are presented: two qualitative interview studies and two quantitative cross-sectional studies. Together, the studies demonstrate that providers are, in general, not very sensitive to patients’ choices and to competition. In the government bill preceding the Patient Choice reform, provider reimbursements were described as a way for money to follow patients’ choices, thereby sharpening the demand signals. Instead, findings indicate that reimbursements mainly are a tool for the regions to steer provider behaviours. The primary care market is also diverse in terms of competition. A large share of the primary healthcare centres is located in local monopoly markets, whereas those located in competitive markets often face rather stiff competition. Moreover, findings show a mixed picture on how market elements promote goals on quality, access and equity. Higher levels of competition are found in more urban local markets and in local markets with a population of higher socioeconomic status. Because competition is unequally distributed, so are conditions for competition to improve performance. Furthermore, providers describe how equity in access has been negatively affected by fee-for-service reimbursements. In summary, there are several obstacles on the supply-side of the Swedish primary care market for the market elements to function as intended in the Patient Choice reform, but also for promoting central policy goals.