Σουηδικό άρθρο από τις 24/01/2020 που το μετέφρασα στα Αγγλικά. Στην Σουηδία η κάθε Νομαρχία έχει δικό της σύστημα με βάση το οποίο αποζημιώνονται από το Κράτος τα Κέντρα Υγείας της. Στο άρθρο αυτό οι συγγραφείς προτείνουν να δημιουργηθεί ένα ενιαίο Εθνικό Σύστημα αποζημίωσης των Κέντρων Υγείας που θα είναι κοινό για όλη την Σουηδία, θα είναι απλούστερο, λιγότερο γραφειοκρατικό και δεν θα απαιτεί τόσο πολύ Διοικητικό προσωπικό ώστε οι περισσευούμενοι πόροι να πηγαίνουν στο Ιατρικό και Νοσηλευτικό προσωπικά και στην βελτίωση του Επιστημονικού έργου των Κέντρων Υγείας. Όπου health center = Κέντρο Υγείας:“Introducing a national reimbursement system in Swedish primary care”.Published: 24/01/2020
Written by: Magnus Isacson ( Chairman of the Swedish Society of General Medicine ), Andreas Thörneby ( Board member of the Swedish Society of General Medicine ).We should design a national and simple reimbursement system in primary care that enables a sharp reduction of administrative tasks, writes two debaters from the Swedish Association for General Medicine.
In Swedish primary care, we have as many reimbursement systems as we have regions. The most important principle systems that exist when it comes to reimbursement to health centers in Sweden are:
1. Remuneration per visit.
2. Remuneration per action performed.
3. Money per listed patient, capitation, often in combination with some weighting system for socio-economic factors, such as Care Need Index (CNI), or care weight, such as Adjusted Clinical Groups (ACG).
4. Compensation for achieved results or quality measures, for example the proportion of diabetics with a good long-term blood sugar.
Often you have the above mentioned system in combination. Earlier in the Stockholm region, the agreements for health centers had very much focus on reimbursement per visit. Now we have shifted to more focus on capitulation with emphasis especially on ACG and to a lesser extent CNI. Remuneration per visit has been drastically reduced.
The reason for this adjustment was that the previous model led to many simple visits, as it gave more money. Visits for elderly and chronically ill patients were not prioritized, as these took longer time and thus provided less money. Paradoxically, a similar system of ongoing compensation per "visit" has been chosen for the online physician companies, of course with the same consequences as seen at Stockholm health centers, that is, many simple and profitable visits.
However, models with performance compensation, for example per visit, also have advantages. They provide incentives for accessibility and "production" and facilitate the start-up of new health centers. The risks of capitating, on the other hand, are poor availability and poor quality, as the income from the health centers is not dependent on performance or results.
Compensation per performed operation can be good if it results in more relevant things being done at the health center, but it also constitutes a detailed management that risks leading to unnecessary measures and that valuable time is lost in administrative measures / registration.
The ACG system is intended to provide higher reimbursement for sicker patients, but unfortunately provides incentives for diagnostic slippage and overdiagnosis and leads to increased time spent on administration rather than patient work. The CNI system for socio-economic weighting has the advantage that it is not possible to influence for the individual unit, but the disadvantage that it is more unspecific and has less clear connection with the health center's actual costs than the ACG.
Compensation for achieved quality parameters has theoretical advantages as an incentive to maintain medical quality and patient safety, but grading and giving money for certain quality parameters inevitably results in prioritizing these measures and having displacement effects in other areas.
We have all these remuneration systems because politicians and officials want to have control of our profession and because they what to be sure that we (the Doctors) do the right things. Unfortunately, regardless of the choice, the systems tend to control errors in different ways. Then we have the biggest problem and that is that primary care in Sweden is severely underfunded and under-dimensioned.
Therefore, we should design a national and simple reimbursement system in primary care that enables a significant reduction of administrative personnel and administrative tasks both centrally and locally. Invest the money on healthcare staff and the opportunity to develop our commitment instead. Introduce a limited and reasonable list of patients within a specific range for each individual general practitioner. Provide compensation mainly on the basis of capitulation, weighted for factors that do not require registration and are not possible to manipulate.
Then have the quality control of the health centers carried out through regular professional audit. Make it mandatory for each general practitioner to perform these audits by reviewing another randomly selected health center regarding compliance with medical guidelines, staff satisfaction, quality metrics, patient involvement, and more.
In the event of deviations or doubts, examining general practitioners can then report to the client, or in some cases to the Swedish Health Ministry, with the possibility of deeper examination and appropriate measures.
The system outlined above would contribute to the necessary re-professionalisation of primary care management, reduced central and local over-administration and increased collegial exchange between health centers with the possibility of dissemination of knowledge and development. The remuneration system would provide greater stability and predictability and thus both better working environment and greater personal responsibility for accessibility, quality and continuity.
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