The Perfect Contract - Does it Exist? : A case study of Health Choice Västerbotten and its reimbursement system, focusing on the effects on motivation and competition

Sammanfattning:

This study investigates the required implementation of the System of Choice in the Swedish County Council of Västerbotten. The System of Choice is a national law with the objective to improve efficiency within primary care in Sweden. This was done by opening the market for more competition and giving the citizens the right to choose where to seek care. The reform was a big change for the organisation of health provision, which had up until the reform been characterized by monopolistic behaviour by county councils as dominant firms.

At the time of this study it had been three years since the beginning of Health Choice, which is the name for the reform in Västerbotten. The aim of this research was to find out if the way in which Västerbotten County Council has chosen to shape Health Choice has led to the fulfilment of the objective of increased competition and thus higher motivation to perform quality care. This has been done by examining the development of the Health Choice and its reimbursement system through the eyes of the primary care providers. The study has further looked at the reasons underlying the result and ways to improve it.

This area is not new ground for research. The organisation of health care is a popular topic all over the world since the population is growing and becoming older, thus putting increased pressure on the provision of health care (WHO, 2010, p. VI). Research has however showed that the optimal organisation of a reimbursement system for the primary care largely depends upon local conditions (Anell, 2005, p. 61). Since there is little previous in-depth information about the outcome of the Health Choice, the approach of this study has been inductive. Due to this exploratory and explanatory nature of the study a qualitative approach was applied.

The data-collection has been done through 14 semi-structured interviews of about an hour each. To be able to catch the effects of the reimbursement system 11 of the interviews were conducted with health centre directors, representing both private and public providers as well as the different regions within the county council. The three other interviews were held with representatives from the county council and the supporting department for the Primary Care Group. The interviews generated transcribed text of 250 pages. This material was sifted and processed using the template analysis approach.

The result shows that the county council‟s attitude to the Health Choice has negatively affected how it has been implemented. Too little resources have been spent on the purchasing department that is responsible for the development of the Health Choice and its reimbursement system. These factors have led to an organisation of Health Choice that discourages private providers to enter the primary care market in Västerbotten and there has thus only been a small increase in competition. A complex system with low continuity, lack of information and focus on the wrong things have led to the value of the reimbursement system as a motivational tool for increasing cost effectiveness and quality of care to be low.