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Patient choice and provider competition: Quality enhancing drivers in primary care?
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.ORCID iD: 0000-0003-4715-4851
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.ORCID iD: 0000-0002-3858-3454
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.ORCID iD: 0000-0002-3921-5522
2019 (English)In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 226, p. 217-224Article in journal (Refereed) Published
Abstract [en]

Patient choice of provider and provider competition have been introduced with the claim that they would lead to improved quality. For this to occur, certain conditions must be fulfilled on both the demand and the supply side. However, supply side-mechanisms – with provider behaviour as central – have been largely neglected in the literature, especially in primary care markets. In this article, we focus on provider behaviour and explore if and how choice and competition function as quality enhancing drivers in Swedish primary care. We explore this through semi-structured interviews with 24 managers and physicians at 13 Swedish primary healthcare centres, conducted from May 2016 to February 2017. The analysis draws on assumptions that for enhanced quality, providers must receive information on patients' choices, analyse it and respond accordingly. One conclusion is that Swedish primary care providers lack information on patients' choices and "exits", which makes it difficult for providers to respond to patients' choices. Furthermore, it is questionable whether choice and competition stimulate enhanced clinical quality. At the same time, choice and competition seems to make providers more aware of accessibility concerns and of their reputation, which they may be stimulated to improve. The article contributes evidence on supply side-mechanisms, and encourages clarification of "quality" in this respect, both on the political arena as well as in theoretical models.

Place, publisher, year, edition, pages
2019. Vol. 226, p. 217-224
Keywords [en]
Sweden, Patient choice, Competition, Quasi-market, Primary care
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
URN: urn:nbn:se:uu:diva-379412DOI: 10.1016/j.socscimed.2019.01.042ISI: 000466251700025PubMedID: 30878640OAI: oai:DiVA.org:uu-379412DiVA, id: diva2:1296525
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2014-4763Available from: 2019-03-15 Created: 2019-03-15 Last updated: 2022-10-31Bibliographically approved
In thesis
1. Marketisation of Swedish Primary Care: Patient Choice, Provider Competition and Payment Incentives
Open this publication in new window or tab >>Marketisation of Swedish Primary Care: Patient Choice, Provider Competition and Payment Incentives
2022 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

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.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2022. p. 85
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1883
Keywords
patient choice, provider competition, payment incentive, reimbursement, primary care, marketisation, Sweden
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Research subject
Health Care Research
Identifiers
urn:nbn:se:uu:diva-487620 (URN)978-91-513-1650-5 (ISBN)
Public defence
2022-12-16, Sal IX, Universitetshuset, Biskopsgatan 3, Uppsala, 09:15 (Swedish)
Opponent
Supervisors
Available from: 2022-11-25 Created: 2022-10-31 Last updated: 2022-11-25

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Vengberg, SofieFredriksson, MioWinblad, Ulrika

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