The Effects of Freedom of Choice in Healthcare

This report presents a systematic review of Swedish and international research on reforms concerning choice in healthcare. The report focuses on how patient choose and how the reforms affect quality, equality, accessibility, and costs.

Over the past few decades, freedom of choice for patients has to an ever greater degree taken a central place in the debate on the management and organisation of healthcare and medical care. Many countries have introduced, or are in the process of introducing, various freedom of choice reforms in healthcare and medical care. In Sweden, one aspect of this development has been statutory freedom of choice within primary care since 1 January 2010. The reform means that all healthcare providers who meet certain basic requirements may set up at a geographical location of their choice within the county council area, and that the choices made by patients govern the reimbursement paid to the provider.

The positive effects most often quoted in connection with the introduction of a system of freedom of choice are a strong status for the patients, increased efficiency and the quality of the operation. The negative criticism has primarily targeted the risk that systems involving freedom of choice will lead to increasing costs and more inequality. However, what effects freedom of choice will have in practice is an empirical question. In conjunction with the implementation of the freedom of choice reforms, several scientific studies have been carried out to examine what effects the introduction has had on factors such as the accessibility of healthcare, equality and medical quality. However, no overview study is currently available that compares the results from international scientific research and the Swedish assessments conducted in the area.

The report features a systematic review of Swedish and international research into how patients choose their healthcare provider and how the freedom of choice reforms affect quality, equality, accessibility and costs. The following issues are addressed in the report:

1. Do patients wish to choose their healthcare provider?

2. On what grounds do patients choose a healthcare provider (waiting times, continuity, travelling time and information on quality)?

3. What are the effects of a free choice of healthcare provider in terms of:

• quality?

• equality?

• accessibility?

• cost and efficiency?

WHAT ARE THE MOST IMPORTANT RESULTS? 

  • The patients valued freedom of choice, and those who made an active choice of provider were more satisfied 

Patients feel that freedom of choice in healthcare has a positive value. A majority of Swedish patients would like to make their own choice of primary care provider. The results also indicate that patients wish to be involved in choosing treatment options. An interesting result is that those patients who make active choices are generally more satisfied with the healthcare they receive. One conceivable explanation may be quite simply that they choose better healthcare providers. It is therefore essential to have a better understanding of both the grounds on which patients choose their healthcare provider and which ones they choose. It appears that a high educational level is an important explanatory factor in individuals’ desire and inclination to make use of freedom of choice.

  • The patients chose their healthcare provider on the basis of proximity and reputation – not medical results 

Patients’ choice of healthcare provider is based to a large extent on their geographical proximity to the healthcare provider, the healthcare provider’s reputation, and the accessibility, continuity and staff expertise offered by the provider. In contrast, information on medical quality was behind patients’ choice of healthcare provider to only a small extent. It may be the case that a healthcare provider’s reputation is also an indicator of medical quality, but this needs to be studied further.

  • Patient satisfaction appears to have increased somewhat 

The studies into quality effects carried out on healthcare choice in primary care in Sweden are difficult to interpret with any certainty. If appears that patient satisfaction has increased somewhat following the introduction of healthcare choice, but it is less certain that we can draw the conclusion from this that the increase is due to the introduction of healthcare choice.

  • The patients now live at a shorter distance from their medical centre

A large number of medical centres have been opened since the healthcare choice reform in Sweden. Travelling times have therefore fallen for a large proportion of the population.

  • The effects on patient waiting times were, however, small

At the same time, the assessments of healthcare choice show that waiting times do not appear to have changed to any great extent. Based on reported data on waiting times and patient measurements, the differences before and after the introduction of healthcare choice are small. With regard to free choice of healthcare provider in specialised healthcare, international studies show that there are certain positive effects on waiting times. It is important to note that no study has shown longer waiting times as a result of freedom of choice in specialised healthcare.

  • The costs have been under control during the introduction of healthcare choice in primary care

Assessments of Swedish healthcare choice show that it has been possible for county councils to avoid increased costs following the introduction of healthcare choice. There are examples from other countries of costs having both increased and fallen as a result of the introduction of freedom of choice.

  • There are deficiencies in knowledge about the effects of freedom of choice in terms of efficiency, medical quality and equality

The results of the literature study show that it is not clear whether or not the introduction of freedom of choice models overall has led to more efficient healthcare. International experiences are few in number and, in part, contradictory. The few assessments of healthcare choice in Sweden that have been identified lend some support to the idea that it is possible to achieve good cost control and an increase in healthcare production while at the same time maintaining the level of quality as perceived by the patient. It is largely unknown what effects freedom of choice models have on medical quality. Knowledge of how equality in healthcare and medical care is affected by the freedom of choice reforms is also incomplete.

WHAT CAN BE UNDERSTOOD FROM THE RESULTS?

A significant lesson from the literature study is that, in many ways, there are deficiencies in knowledge of the effects of freedom of choice in the various areas of healthcare and medical care. One explanation, in Sweden’s case, is that the freedom of choice reforms were introduced recently, and that the assessment and research is still in its initial stages. In other countries, freedom of choice has rarely been the central issue as it has often been in place for a long time and has not, therefore, been regarded as quite as interesting as an object of study. In order to gain better knowledge of the effects of freedom of choice, it is essential to work on improving opportunities for monitoring, assessment and research.

The report establishes that there is a lack of knowledge in Sweden on how healthcare choice in primary care has affected accessibility for various patient groups. As the Swedish Health and Medical Services Act stipulates that healthcare must be provided on equal terms and conditions, it is vital to chart developments in the equality aspect. In this context, the results of the report underline the importance of studying healthcare consumption in a way that makes it possible to see how healthcare is provided to various patient groups. This type of analyses requires – with due regard to integrity interests – access to data sources that allow information on costs, healthcare contacts, patient-perceived quality, medical needs and medical quality to be linked at patient level. A further prerequisite in order for studies into freedom of choice systems in primary care to achieve their full potential is for the regions and county councils to have fully comparable data to describe the content of their healthcare provision. This is currently absent. For example, the same terms and concepts are not used.

It is also pointed out in the report that anyone seeking to create a picture of developments at national level is obliged to fit together the pieces from various studies. This points to the need for coordinated national monitoring and assessment. The county councils’ self-determination in terms of the specific design of the freedom of choice models also means that there should be good opportunities to learn on the basis of “best practice” within the various areas. It is also essential to create a culture in which monitoring and evaluation take on a central role in the reform work at both local and regional level, and where research forms an integral part.

The study also points to the importance of continuing to study how socio-economic conditions – for example, education level – affect people’s inclination to make active choices of healthcare provider. On the basis of established knowledge, there is an urgent need to examine how groups with worse socio-economic conditions may be supported in making use of their opportunities to make choices. The results that show that healthcare providers’ informal reputations also lie behind people’s choice of provider emphasise the importance of access to social contacts and networks. Overall, it is essential to illustrate how the provision of information to various patient groups can be supported and developed. This is particularly relevant as the study also points to a conceivable explanation of the fact that people who make more active choices are generally more satisfied with their healthcare being that they simply receive better healthcare.

The literature review has not focused on the specific design of the freedom of choice reforms, such as the reimbursement systems. It is vital to take this dimension into consideration, however, in order to achieve more in-depth knowledge and to use this in practice in the work being done to improve and develop healthcare.

WHAT LESSONS CAN BE LEARNED?

  • It is essential to provide strength and support to patients in their choice of healthcare provider

An important prerequisite for a freedom of choice system is that citizens and patients must be able to make active, well-informed choices. The literature review shows that a high educational level is an important explanatory factor in individuals’ desire and inclination to make use of freedom of choice. It is important, therefore, for citizens and patients to be given support in choosing their healthcare provider that is fit for purpose. Above all, the measures should be aimed at groups with worse socio-economic conditions and should be directed towards primary care. Providing support to these groups in making their choices is an important complement to other quality assurance measures.

  • It is essential to work to ensure that information on medical quality forms the basis of patients’ choice of healthcare provider to a greater extent than is currently the case

In practice, medical quality is not a factor that is used to any great extent by patients when they choose their healthcare provider. One explanation may be that in practice there is no widespread or, from a patient’s point of view, usable information about quality, and that this is the reason why patients do not consider it important when choosing their healthcare provider. If this is correct, it is essential to improve the information given to patients about the medical quality of healthcare providers as there are currently deficiencies in this information, particularly in primary care.

  • It is essential to encourage controlled studies that have a greater chance both of finding any causal connections and of distinguishing the effects of reform from other concurrent changes taking place in the healthcare and medical care system

Most Swedish studies of the freedom of choice systems are built around having studied the change before and after the introduction of healthcare choice. This makes it difficult to state whether a change in waiting times, for example, is an effect of healthcare choice in itself or an effect of some other healthcare reform. There is generally a great need for future studies, such as randomised and experimental ones, that examine the effect of a freedom of choice system. More comprehensive studies are also needed of the effects of freedom of choice reforms on various patient groups’ access to healthcare. Finally, it is important to illustrate further the effects that various designs of healthcare choice systems have on quality and costs, for example. The fact that all county councils in practice have their own design of healthcare choice system creates unique opportunities to study this in Sweden.