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Table 2 Overview of potential and observed effects of the PHC Choice reform and reimbursement systems on structure, process and outcome in PHC in Sweden

From: Equity aspects of the Primary Health Care Choice Reform in Sweden – a scoping review

  PHC Choice Reform Reimbursement system based on fee-for service Comments - impact on equity and need-based care
Structure - Access, resources
 Number of practices Increased   Less increase in disadvantaged areas
 Practice distribution Providers’ choice determines practice distribution   Reduced political influence on distribution by need, may cause maldistribution
 Resource allocation Patients’ choice determines resource allocation between practices Short visits are incentivised = more income Reduced political influence on resource allocation by need
 GP’s work environment Patients become customers - change in professional focus Many short visits are incentivised Priority on those with lesser needs
Process - Delivery of health care
 Number of visits to PHC Increased Increased Greater increase for those with lesser needs
 Prioritisation of patients Patients as customers Focus on short visits by healthier patients More demand-driven care. Less focus on those with greater need
 Integrated care More complex to achieve integration, competition Integrated care not incentivised More difficult for those in need of integrated care
 Holistic care De-limited, differentiated PHC assignments (e.g. ENT, gynaecology, child health) One visit, one problem (short itemized visits) Itemized care not beneficial for those with complex needs
 Inter-professional care Focus on doctors Less teamwork doctors and nurses No benefit for those in need of inter-professional care
Outcomes – impact on health
 Health among those with complex needs Coordination and integration more difficult Counteracts holistic care Potentially adverse effects on those with greater needs
 Treatment impact Reduced focus on prevention, more emphasis on cure Focus on short visits - curative care for self-limiting diseases Increase in preventable health problems?
 Population health Focus only on listed individuals limits population impact Less emphasis on health promotion and on collaboration with other agencies Reduces PHC impact on population health