Patient choice, entry, and the quality of primary care: Evidence from Swedish reforms

Abstract

Policies aiming to spur quality competition among health care providers are ubiquitous, but their impact on quality is ex ante ambiguous, and credible empirical evidence is lacking in many contexts. This study contributes to the sparse literature on competition and primary care quality by examining recent competition enhancing reforms in Sweden. The reforms aimed to stimulate patient choice and entry of private providers across the country but affected markets differently depending on the initial market structure. We exploit the heterogeneous impact of the reforms in a difference-in-differences strategy, contrasting more and less exposed markets over the period 2005-2013. Although the reforms led to substantially more entry of new providers in more exposed markets, the effects on primary care quality were modest: We find small improvements of patients' overall satisfaction with care, but no consistently significant effects on avoidable hospitalisation rates or satisfaction with access to care. We find no evidence of economically meaningful quality reductions on any outcome measure.

Performing Through Privatization: An Ecological Natural Experiment of the Impact of the Swedish Free Choice Reform on Ambulatory Care Sensitive Conditions

“…The pattern of slightly increasing trends in hospitalizations for chronic ACSC turning toward downward trend after 2010 have been noted before (28), and has been interpreted as reflecting improved interventions in outpatient care for diseases such as chronic heart failure and chronic obstructive lung disease. The fact that we were unable to attribute this change or the increase in emergency visits to features of the reform overall corresponds to findings from a preliminary study following avoidable hospitalizations up to 2013 (9), and warrants a comment on other possible causes of the observed changes. First, as noted above, the positive development seen for to chronic conditions hospitalizations could reflect universal improvements in the treatment and management of chronic conditions not restricted to primary care.…”

“…Initial reports by public agencies indicated that implementation of the reform was coupled with increased new establishments of private health care providers, increased number of health care visits, and a maintained level of quality, but with an inconclusive and debated effect on the actual gains in terms of health care performance (3,4,8). Moreover, recent studies including those summarized in a scoping review in 2017 suggested that the increased number of PHC visits had been concentrated particularly to areas with a high patient-provider ratio and to socioeconomically advantaged groups (2,9,10). When it comes to quality and performance, one early assessment (up to 2013) found small improvements of patient' satisfaction with care but no significant effects on avoidable hospitalizations or satisfaction with access to care (9).…”

“…Moreover, recent studies including those summarized in a scoping review in 2017 suggested that the increased number of PHC visits had been concentrated particularly to areas with a high patient-provider ratio and to socioeconomically advantaged groups (2,9,10). When it comes to quality and performance, one early assessment (up to 2013) found small improvements of patient' satisfaction with care but no significant effects on avoidable hospitalizations or satisfaction with access to care (9). Furthermore, it has also been suggested that the reform had negatively affected provision of services for patients with complex needs, which may in turn have lessened the impact of PHC on overall population health (2,11).…”

Associations between structures and resources of primary care at the district level and health outcomes: a case study of diabetes mellitus care in Thailand

“… 26 However, another study found no significant impact of structural concentration on the rate of hospitalizations for ACSCs. 27 Background differences in health services systems across countries may be an important cause of the differences in these results.…”

Conditions and Barriers for Quality Improvement Work. A Qualitative Study of How Professionals and Health Centre Managers Experience Audit and Feedback Practices in Swedish Primary Care

“…The outcome of these reforms is debated and the results from studies are inconclusive (12,13). Overall, however, studies indicate that reforms have had little impact on the capacity and quality of PC (14). Swedish PC still has a low proportion of GPs (about 16%) in comparison with other high-income countries (15,16).…”