Small is beautiful? Explaining resident satisfaction in Swedish nursing home care.

BACKGROUND: Resident satisfaction is an important aspect of nursing home quality. Despite this, few studies have systematically investigated what aspects of nursing home care are most strongly associated with satisfaction. In Sweden, a large number of processual and structural measures are collected to describe the quality of nursing home care, though the impact of these measures on outcomes including resident satisfaction is poorly understood. METHODS: A cross-sectional analysis of data collected in two nationally representative surveys of Swedish eldercare quality using multi-level models to account for geographic differences. RESULTS: Of the factors examined, nursing home size was found to be the most important predictor of resident satisfaction, followed by the amount of exercise and activities offered by the nursing home. Measures of individualized care processes, ownership status, staffing ratios, and staff education levels were also weakly associated with resident satisfaction. Contrary to previous research, we found no clear differences between processual and structural variables in terms of their association with resident satisfaction. CONCLUSIONS: The results suggest that of the investigated aspects of nursing home care, the size of the nursing home and the amount activities offered to residents were the strongest predictors of satisfaction. Investigation of the mechanisms behind the higher levels of satisfaction found at smaller nursing homes may be a fruitful avenue for further research.

Market-orienting reforms in rural health care in Sweden: how can equity in access be preserved?

BACKGROUND: Health care provision in rural and urban areas faces different challenges. In Sweden, health care provision has been predominantly public and equitable access to care has been pursued mainly through public planning and coordination. This is to ensure that health needs are met in the same manner in all parts of the country, including rural or less affluent areas. However, a marketization of the health care system has taken place during recent decades and the publicly planned system has been partially replaced by a new market logic, where private providers guided by financial concerns can decide independently where to establish their practices. In this paper, we explore the effects of marketization policies on rural health care provision by asking how policy makers in rural counties have managed to combine two seemingly contradictory health policy goals: to create conditions for market competition among health care providers and to ensure equal access to health care for all patients, including those living in rural and remote areas. METHODS: A qualitative case study within three counties in the northern part of Sweden, characterized by vast rural areas, was carried out. Legal documents, the "accreditation documents" regulating the health care quasi-markets in the three counties were analyzed. In addition, interviews with policy makers in the three county councils, representing the political majority, the opposition, and the political administration were conducted in April and May 2013. RESULTS: The findings demonstrate the difficulties involved in introducing market dynamics in health care provision in rural areas, as these reforms not only undermined existing resource allocation systems based on health needs but also undercut attempts by local policy makers to arrange for care provision in remote locations through planning and coordination. CONCLUSION: Provision of health care in rural areas is not well suited for market reforms introducing competition, as this may undermine the goal of equity in access to health care, even in a publicly financed health care system.

Do public nursing home care providers deliver higher quality than private providers? Evidence from Sweden.

BACKGROUND: Swedish nursing home care has undergone a transformation, where the previous virtual public monopoly on providing such services has been replaced by a system of mixed provision. This has led to a rapidly growing share of private actors, the majority of which are large, for-profit firms. In the wake of this development, concerns have been voiced regarding the implications for care quality. In this article, we investigate the relationship between ownership and care quality in nursing homes for the elderly by comparing quality levels between public, for-profit, and non-profit nursing home care providers. We also look at a special category of for-profit providers; private equity companies. METHODS: The source of data is a national survey conducted by the Swedish National Board of Health and Welfare in 2011 at 2710 nursing homes. Data from 14 quality indicators are analyzed, including structure and process measures such as staff levels, staff competence, resident participation, and screening for pressure ulcers, nutrition status, and risk of falling. The main statistical method employed is multiple OLS regression analysis. We differentiate in the analysis between structural and processual quality measures. RESULTS: The results indicate that public nursing homes have higher quality than privately operated homes with regard to two structural quality measures: staffing levels and individual accommodation. Privately operated nursing homes, on the other hand, tend to score higher on process-based quality indicators such as medication review and screening for falls and malnutrition. No significant differences were found between different ownership categories of privately operated nursing homes. CONCLUSIONS: Ownership does appear to be related to quality outcomes in Swedish nursing home care, but the results are mixed and inconclusive. That staffing levels, which has been regarded as a key quality indicator in previous research, are higher in publicly operated homes than private is consistent with earlier findings. The fact that privately operated homes, including those operated by for-profit companies, had higher processual quality is more unexpected, given previous research. Finally, no significant quality differences were found between private ownership types, i.e. for-profit, non-profit, and private equity companies, which indicates that profit motives are less important for determining quality in Swedish nursing home care than in other countries where similar studies have been carried out.

Free establishment of primary health care providers: effects on geographical equity.

BACKGROUND: A reform in 2010 in Swedish primary care made it possible for private primary care providers to establish themselves freely in the country. In the former, publicly planned system, location was strictly regulated by local authorities. The goal of the new reform was to increase access and quality of health care. Critical arguments were raised that the reform could have detrimental effects on equity if the new primary health care providers chose to establish foremost in socioeconomically prosperous areas. The aim of this study is to examine how the primary care choice reform has affected geographical equity by analysing patterns of establishment on the part of new private providers. METHODS: The basis of the design was to analyse socio-economic data on individuals who reside in the same electoral areas in which the 1411 primary health care centres in Sweden are established. Since the primary health care centres are located within 21 different county councils with different reimbursement schemes, we controlled for possible cluster effects utilizing generalized estimating equations modelling. The empirical material used in the analysis is a cross-sectional data set containing socio-economic data of the geographical areas in which all primary health care centres are established. RESULTS: When controlling for the effects of the county council regulation, primary health care centres established after the primary care choice reform were found to be located in areas with significantly fewer older adults living alone as well as fewer single parents - groups which generally have lower socio-economic status and high health care needs. However, no significant effects were observed for other socio-economic variables such as mean income, percentage of immigrants, education, unemployment, and children <5 years. CONCLUSIONS: The primary care choice reform seems to have had some negative effects on geographical equity, even though these seem relatively minor.

Recentralizing healthcare through evidence-based guidelines - striving for national equity in Sweden.

BACKGROUND: The Swedish government has increasingly begun to rely on so called informative governance when regulating healthcare. The question this article sets out to answer is: considered to be "the backbone" of the Swedish state's strategy for informative governance in healthcare, what kind of regulatory arrangement is the evidence-based National Guidelines? Together with national medical registries and an extensive system of quality and efficiency indicators, the National Guidelines constitutes Sweden's quality management system. METHODS: A framework for evaluating and comparing regulatory arrangements was used. It asks for instance: what is the purpose of the regulation and are regulation methods oriented towards deterrence or compliance? RESULTS: The Swedish National Guidelines is a regulatory arrangement intended to govern the prioritizations of all decision makers - politicians and administrators in the self-governing county councils as well as healthcare professionals - through a compliance model backed up by top-down benchmarking and built-in mechanisms for monitoring. It is thus an instrument for the central state to steer local political authorities. The purpose is to achieve equitable and cost-effective healthcare. CONCLUSIONS: This article suggests that the use of evidence-based guidelines in Swedish healthcare should be seen in the light of Sweden's constitutional setting, with several autonomous levels of political authority negotiating the scope for their decision-making power. As decision-making capacity is relocated to the central government - from the democratically elected county councils responsible for financing and provision of healthcare - the Swedish National Guidelines is part of an ongoing process of healthcare recentralization in Sweden, reducing the scope for local decision-making. This represents a new aspect of evidence-based medicine (EBM) and clinical practice guidelines (CPGs).

Does voluntary health insurance reduce the use of and the willingness to finance public health care in Sweden?

Voluntary private health insurance (VHI) has generally been of limited importance in national health service-type health care systems, especially in the Nordic countries. During the last decades however, an increase in VHI uptake has taken place in the region. Critics of this development argue that voluntary health insurance can undermine support for public health care, while proponents contend that increased private funding for health services could relieve strained public health care systems. Using data from Sweden, this study investigates empirically how voluntary health insurance affects the public health care system. The results of the study indicate that the public Swedish health care system is fairly resilient to the impact of voluntary health insurance with regards to support for the tax-based funding. No difference between insurance holders and non-holders was found in willingness to finance public health care through taxes. A slight unburdening effect on public health care use was observed as VHI holders appeared to use public health care to a lesser extent than those without an insurance. However, a majority of the insurance holders continued to use the public health care system, indicating only a modest substitution effect.

Preserving social equity in marketized primary care: strategies in Sweden.

A primary care choice reform launched in Sweden in 2010 led to a rapid growth of private providers. Critics feared that the reform would lead to an increased tendency among new, profit-driven, providers, to select patients with lower health risks. Even if open risk selection is prohibited, providers can select patients in more subtle ways, such as establishing their practices in areas with higher health status. This paper investigates to what extent strategies were employed by local governments to avoid risk selection and whether there were any differences between left- and right-wing governments in this regard. Three main strategies were used: risk adjustment of the financial reimbursements on the basis of health and/or socio-economic status of listed patients; design of patient listing systems; and regulatory requirements regarding the scope and content of the services that had to be offered by all providers. Additionally, left-wing local governments were more prone than right-wing governments to adopt risk adjustment strategies at the onset of the reform but these differences diminished over time. The findings of the paper contribute to our understanding of how social inequalities may be avoided in tax-based health care systems when market-like steering models such as patient choice are introduced.

Health insurance for the healthy? Voluntary health insurance in Sweden.

BACKGROUND: In Sweden, voluntary health insurance is held only by a very small part of the population, but uptake has grown rapidly since 2000. So far, little is known about who purchases this insurance and what the insurance plans contain. AIM: To provide a comprehensive description of the coverage and content of voluntary health insurance in Sweden. METHODS: Data from a national survey (Riks-SOM 2016) were used to estimate insurance coverage in different population groups. Additionally, a qualitative content analysis of the voluntary health insurance plans from seven of the largest insurance companies in Sweden was conducted. RESULTS: Voluntary health insurance was found to be more common among high income-earners, individuals employed in the private sector, business owners, and white-collar workers. Insurance benefits varied from visiting a general practitioner to more specialised treatments like knee or hip surgery. Pre-existing medical conditions, emergency medicine, highly specialised care and ongoing chronic care was excluded from the insurance plans. CONCLUSION: Work-related factors such as employment sector, occupation and income appeared to be key determinants for VHI uptake in Sweden. Since the insurance plans included several restrictions, individuals with high care needs are excluded. Taken together, the results indicate that voluntary health insurance in Sweden provide benefits foremost for the healthy and wealthy.

Risk selection in primary care: a cross-sectional fixed effect analysis of Swedish individual data.

OBJECTIVE: To assess socioeconomic differences between patients registered with private and public primary healthcare centres. DESIGN: Population-based cross-sectional study controlling for municipality and household. SETTING: Swedish population-based socioeconomic data collected from Statistics Sweden linked with individual registration data from all 21 Swedish regions. PARTICIPANTS: All individuals residing in Sweden on 31 December 2015 (n=9 851 017) were included in the study. PRIMARY OUTCOME MEASURES: Registration with private versus public primary healthcare centres. RESULTS: After controlling for municipality and household, individuals with higher socioeconomic status were more likely to be registered with a private primary healthcare provider. Individuals in the highest income quantile were 4.9 percentage points (13.7%) more likely to be registered with a private primary healthcare provider compared with individuals in the lowest income quantile. Individuals with 1-3 years of higher education were 4.7 percentage points more likely to be registered with a private primary healthcare provider compared with those with an incomplete primary education. CONCLUSIONS: The results show that there are notable differences in registration patterns, indicating a skewed distribution of patients and health risks between private and public primary healthcare providers. This suggests that risk selection behaviour occurs in the reformed Swedish primary healthcare system, foremost through location patterns.

Privatization of social services: quality differences in Swedish elderly care.

One of the major policy trends in recent decades has been the privatization of social services. This trend has also reached Sweden, a welfare state with health care and social service sectors that previously had almost no private providers. One of the most affected areas is elderly care, i.e. home-help services and residential care provided to citizens older than 65 years, where the proportion of private providers increased from 1% in 1990 to 16% in 2010. The ongoing privatization in Sweden and many other countries has raised important questions regarding the consequences of this policy transformation. In this paper, we present a cross-sectional study comparing the quality of services in private and public elderly care. Using statistics from 2007 displaying a variety of quality dimensions covering over 99% of all elderly care residents in Sweden, we were able to show that privatization is indeed associated with significant quality differences. Structural quality factors such as the number of employees per resident was significantly smaller (-9%) in private elderly care. On the other hand, the proportion of residents participating in the formulation of their care plan (+7%), the proportion of elderly with a reasonable duration between evening meal and breakfast (+15%), and the proportion of elderly offered different food alternatives (+26%) were significantly in favour of private contractors. Our conclusion is that private care providers seem to emphasize service aspects rather than structural prerequisites for good care.