Health care needs only explain one percent of identified differences between inhabitants in different Swedish regions when it comes to utilizing primary care. Moreover, a large portion of this variation remains unexplained even after taking a number of different factors into account. This represents a problem as the overall goal is to provide health care based on need and on equal terms throughout the country. According to health economist Naimi Johansson in a new SNS report, a national primary care register is needed to come to grips with the scope and causes of unjustified differences.
The costs related to health care and, above all, the consumption of such services differ between the 21 regions in Sweden. Naimi Johansson has studied the scope of these regional differences and the extent to which they may be linked to differences related to needs, demographics, socioeconomic factors and health care resources.
Small regional differences with regard to total costs
The SNS report analyzes differences in terms of total costs for health care, drug costs and number of physician visits. Regional differences are small from an international perspective but differ depending on whether you focus on costs or utilization.
During the period 2014–2019, Gotland exhibited the highest health care costs per capita while the lowest costs were reported in Västra Götaland. This difference amounted to 19 percent, which is low compared to other countries. The corresponding figure is about 200 percent for American hospital referral regions, 45 percent for German counties and 24 percent for Dutch provinces.
The differences related to drug costs are somewhat higher, as there is a 25-percent difference between the region with the highest drug costs and the one with the lowest.
Fewer physician visits per capita outside Stockholm
The greatest differences between Swedish regions concern the number of physician visits per capita, even though the number of physician visits per capita in Sweden is low from an international perspective. The average number of physician visits per capita in the EU is more than twice as high as in Sweden. What is remarkable in the Swedish context is how Stockholm stands out. During a few years in the 2010s, almost twice as many physician visits per capita were made in Stockholm compared to Östergötland and Jämtland Härjedalen, which were the regions reporting the lowest number of visits per capita. In Stockholm, the highest number of visits per capita occurred in specialist care (1.6 visits) and primary care (2 visits).
“It is unlikely that these differences are the result of residents in Stockholm having a much greater need for health care services. This may rather be related to a higher level of accessibility in Stockholm and the fact that primary care centers in Stockholm to some extent are reimbursed based on the number of visits,” argues Naimi Johansson, health economist at the University Health Care Research Center, Region Örebro and the Institute of Medicine, University of Gothenburg.
Socioeconomic factors and health care resources as measured by, for example, access to physicians and primary care centers per capita explain one-third of the variation in the number of primary care visits.
According to Naimi Johansson, the fact that differences linked to health care needs only seem to offer a limited explanation represents a problem and is difficult to reconcile with the stipulated goal of equal care in Sweden. She also notes that a large part of the regional variation is not in any way linked to any of the aspects studied. Two-thirds of the identified differences regarding primary care visits and half the differences related to visits to specialist physicians remain unexplained in her study.
This analysis of regional variation in physician visits cannot tell us anything about causal relationships. Nevertheless, it does show how this variation is associated with factors that should have an impact on differences in health care consumption, such as the residents’ health care needs.
“We need better data to understand the causes behind this regional variation, especially when it comes to primary care. A national primary care register at the individual level should be introduced so that we can make relevant comparisons between regions. Furthermore, the current National Patient Register should also include resources other than physicians. In order to learn more about the role of health care needs, we need a measure of inhabitants’ morbidity,” says Naimi Johansson.
This report is published as part of the SNS research project Organizing and Financing Health Care and Elderly Care.
Regarding the study
> This SNS report is based on two research studies on regional differences in Swedish health care written by Naimi Johansson, Niklas Jakobsson and Mikael Svensson.
> By using two different data sources and two different empirical methods, they study possible explanations for the identified variation in physician visits and drug costs.
> First, regional variation is measured without taking other factors into account. This is followed by adding one variable group at a time to estimate how much of the variation is explained by each variable groups.
> Health care needs, measured as regional mortality, are shown to explain some of the variation in specialist visits but only exhibit a very limited relationship to the variation in primary care visits. Part of the latter variation, however, is explained by accessibility.
> In the analysis of drug costs, the results show that the variation is mostly (90%) the result of differences between individuals, while only a small part (10%) is driven by differences in region-specific factors.