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SWEDEN What is covered? Services: There is no defined benefits package. The publicly financed health system covers public health and preventive services; primary care; inpatient and outpatient specialized care; emergency care; inpatient and outpatient prescription drugs; mental health care; rehabilitation services; disability support services; patient transport support services; home care and long-term care, including nursing home care and hospice care; dental care and optometry for children and young people; and, with limited subsidies, adult dental care. As the responsibility for organizing and financing health care rests with the county councils and municipalities, services vary throughout the country. Cost-sharing and out-of-pocket spending: In 2013, about 16 percent of all expenditures on health were private, and of these 93 percent were out-of-pocket (Statistics Sweden, 2015a). The majority of out-of-pocket spending is for drugs. The county councils set copayment rates per health care visit and per bed-day, leading to variation across the country. Providers cannot charge above the scheduled fee. The table below shows fee ranges for 2014. Service Fee Range (2014) Swedish Kroner U.S. Dollars Primary care physician visit 100–300 11–34 Hospital physician consultation 200–350 22–39 Hospitalization per day 80–100 9–11 Source: SALAR, 2015. Nationally, annual out-of-pocket payments for health care visits are capped at SEK1,100 (USD123) per individual. In all county councils, people under age 18—and in most county councils, people under 20—are exempt from user charges for visits. Dental care: Dental and pharmaceutical benefits are determined at the national level. People under 20 have free access to all dental care. People 20 or older receive a fixed annual subsidy of SEK150–SEK300 (USD17– USD34), depending on age, for preventive dental care. For other dental services, within a 12-month period patients 20 or older pay the full cost of services up to SEK3,000 (USD335), 50 percent of the cost for services between SEK3,000 and SEK15,000 (USD1,676), and 15 percent of costs above SEK15,000. There is no cap on user charges for dental care. Prescription drugs: Individuals pay the full cost of prescribed medications up to SEK1,100 (USD123) annually, after which the subsidy gradually increases to 100 percent. The annual ceiling for out-of-pocket payments for prescriptions is SEK2,200 (USD246) for adults. A separate annual out-of-pocket maximum of SEK2,200 applies collectively to all children belonging to the same family. For certain prescription drugs not on the National Drug Benefits Scheme and not subject to reimbursement, patients must pay the full price. Safety net: Because the Swedish health care system is designed to be socially responsible and equity-driven, all social groups are entitled to the same benefits. The ceilings on out-of-pocket spending apply to everyone, and the overall cap on user charges is not adjusted for income. Children, adolescents, pregnant women, and the elderly are generally targeted groups, exempted from user charges or granted subsidies for certain services such as maternity care or vaccination programs. * Please note that, throughout this profile, all figures in USD were converted from SEK at a rate of about SEK8.95 per USD, the purchasing power parity conversion rate for GDP in 2014 reported by OECD (2015) for Sweden. 154 The Commonwealth Fund
How is the delivery system organized and financed? SWEDEN The health system is highly integrated. An important policy initiative driving structural changes since the 1990s has been the shifting of inpatient care to outpatient and primary care, and the concentration of highly specialized care in academic medical centers. All provider fees are set by county councils, leading to variation across the country. Public and private physicians (including hospital specialists), nurses, and other categories of health care staff at all levels of care are predominantly salaried employees. The average monthly salary for a physician with a specialist degree (including specialists in general medicine) was SEK73,000 (USD8,157) in 2014 (Statistics Sweden, 2015b). There is no regulation prohibiting physicians (including specialists) and other staff who work in public hospitals or primary care practices from also seeing private patients outside the public hospital or primary care practice. Employers of health care professionals, however, may establish such rules for their employees. Primary care: Primary care accounts for about 20 percent of all expenditures on health, and about 16 percent of all physicians work in this setting (Swedish Medical Association, 2013, 2014). Primary care has no formal gatekeeping function. Team-based primary care, with general practitioners, nurses, midwives, physiotherapists, psychologists, and gynecologists, is the main form of practice. There are, on average, four general practitioners in a primary care practice. General practitioners or district nurses are usually the first point of contact for patients. District nurses employed by municipalities also participate in home care and regularly make home visits, especially to the elderly; they have limited prescribing authority. People may register with any public or private provider accredited by the local county council, with most individuals registering with a practice instead of a physician. Registration is not required to visit a practice. There are more than 1,100 primary care practices, of which 40 percent are privately owned. Providers (public and private) are paid a combination of fixed payment for their registered individuals (about 80% of total capitated payment), fee-for-service (17%–18%), and performance-related payment (2%–3%) for achieving quality targets in such areas as patient satisfaction, enrollment in national registers, compliance with guidelines based on evidence-based medicine, and recommendations from county council drug formulary committees. Outpatient specialist care: Outpatient specialist care is provided at university and county council hospitals and in private clinics. Patients have a choice of specialist. Public and private providers are paid through the same fixed, prospective, per-case payments (based on diagnosis-related groups), complemented by price or volume ceilings and quality components. Administrative mechanisms for direct patient payments to providers: Patients normally pay the provider fee up front for primary care and other outpatient visits. In most cases, it is also possible for patients to pay later. After-hours care: Primary care providers are required to provide after-hours care in accordance with the conditions for accreditation in each county council. Practices in proximity to each other (normally three to five practices) collaborate on after-hours arrangements. Through their websites and phone services, providers advise their registered patients where to go for care. Staff providing after-hours primary care services normally include general practitioners as well as nurses. There is no special arrangement for provider payment, and the same copayments apply as those during regular hours (see above, “Cost-sharing and out-of-pocket spending”). Information regarding after-hours patient visits is routinely sent to the practice where the patient is registered. In addition, seven university hospitals and about 50 county council hospitals provide full emergency services 24 hours a day. All county councils and regional bodies provide information on how and where to seek care through their websites and a national phone line, with medical staff available all day to give treatment advice. Moreover, all county councils and their regional counterparts collaborate to provide online information about pharmaceuticals, medical conditions, and pathways for seeking care. A similar private collaboration exists as well. International Profiles of Health Care Systems, 2015 155
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JANUARY 2016 2015 International Pro
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2015 International Profiles of Heal
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Table 1. Health Care System Financi
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Table 3. Selected Health System Per
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The Australian Health Care System,
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AUSTRALIA low-income adults, childr
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AUSTRALIA In 2013, the federal gove
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References AUSTRALIA Australian Bur
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CANADA What is covered? Services: T
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CANADA funding to 145 not-for-profi
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CANADA Organization of the Health S
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CANADA provides recommendations to
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CANADA Health Council of Canada (20
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CHINA Private health insurance: Com
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CHINA is not substantially more exp
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CHINA Organization of the Health Sy
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CHINA References Chen, X. (2014).
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DENMARK In addition, nearly 1.5 mil
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DENMARK Social psychiatry and care
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DENMARK Quality data for a number o
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DENMARK portion is small, it makes
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ENGLAND immunization, and vaccinati
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ENGLAND Hospitals: Publicly owned h
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ENGLAND Organization of the Health
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ENGLAND How are costs contained? Ra
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ENGLAND Organisation for Economic C
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FRANCE VHI finances 13.8 percent of
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FRANCE The average income of primar
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FRANCE What are the key entities fo
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FRANCE inequities in prevention rel
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FRANCE Nolte, E., C. Knai, and M. M
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GERMANY There were 42 substitutive
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GERMANY The 16 state governments de
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GERMANY management system, by the s
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GERMANY What major innovations and
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INDIA Private health insurance: The
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INDIA provide after-hour care, reim
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INDIA are provided by other ministr
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INDIA How are costs contained? Ther
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ISRAEL Together, these two types of
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ISRAEL Primary care physicians are
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ISRAEL Organization of the Health S
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ISRAEL • Using electronic health
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ITALY during hospitalization (Thoms
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ITALY Some regions are promoting ca
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ITALY Organization of the Health Sy
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Page 108 and 109: JAPAN What is covered? Services: Al
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Page 116 and 117: THE NETHERLANDS receive faster acce
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Page 134 and 135: NORWAY Primary, preventive, and nur
Page 136 and 137: NORWAY Patients are free to choose
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Page 140 and 141: NORWAY The National System for the
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Page 144 and 145: SINGAPORE Medifund is the governmen
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Page 156 and 157: SWEDEN Hospitals: There are seven u
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Page 172 and 173: UNITED STATES What is covered? Serv
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Page 176 and 177: UNITED STATES The Institute of Medi
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