Episode 5 – Healthcare in Kry-sis?

One cannot talk about the Nordic Welfare state without talking about its health care system. It is known worldwide for its universal care based on equity, public funding and innovative practices. So in this episode, we give a short introduction into its principles but also look more in depth into current challenges in Sweden and Finland. We talk about inequalities due to private insurance and ask if private digital care-providers are actually a good alternative to cut health care expenses.

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Main PointS

General

  • The Nordic healthcare system has a long heritage and is also known in many country for being deeply rooted in the Nordic Wellfare System Model, rooted in different fundamental values: 

→ primary and preventive healthcare → occupational health standards

→ taxation based (75-85%) [2] and locally administrated (require co-payments by patients however) → markets have a low level of influence on the functioning of healthcare systems

→ equity and equality are important priorities. 

→ but productivity and efficiency are becoming more important

→ decentralized system (except Norway): meaning that the counties, regions and cities are responsible

  • Issues:

→ budgetary pressures 

→ ageing population. 

→ lifestyle changes

→ waiting times [1]

The Privatization of the Health Care System

  • Like in many European countries and also as we have heard in previous episodes, during the 1990s and the rise of neoliberalism during the economic crisis many previously completely public and state-owned sectors became privatized. 
  • The idea was to become more productive and efficient and cut costs for the state

One of those sectors is also the Health Care System: Healthcare costs have in recent years increased rapidly in the Nordic countries due the pressures outlined above.

However, the overall economic burden (as a share of GDP) has been relatively stable over the past decade, ranging from 8.5% in Iceland to 10.9% in Sweden (2017). This is average for OECD post-industrial societies, but 40% less than in the United States. [2]

While we see a general shift in health care in all Nordic Countries, the reforms have been different. Even though we will talk about challenges of this development, it generally increased choice of provider, a more active role of the citizen and better specialized treatment [3].

Sweden, for example, adapted Thatcher inspired reforms initiated purchaser-provider split for hospitals, but has gradually returned from the idea to more cooperation than competition [3]

Sweden

  • Vardcentralen (family care centers): were established in the 1990s and from then on patience had the choice to choose their family care and GPs. Due to a change in the payment system and financial incentives, we have now public family care centers and private (but publicly-financed) providers [3]
  • Decentralized: in Sweden the counties, regions and municipalities are largely responsible for the healthcare system [3]
  • role of public health: Swedish National Institute for Public Health (SNIPH) monitors and coordinates implementation

→ overall aim: “to create social conditions which ensure good health, on equal terms, for the entire population” [3]

Also if we look at the health care system, generally, Sweden has one of the best systems in the world:

  • Sweden has the third lowest child mortality in the world (2.5 out of 1.000 thats half of the mortality in the UK) [4]

→ mainly due to maternal health and more equal distribution of health services [5]

But there are also issues:

  • Since people can choose their public health care provider, there has been a raise in racism against non-white doctors. [6]

Kry.se

  • It is part of the private but public funded family care centers, only that they operate mainly online but also nowadays have their own centers and do heavy advertisement
  • You can book there online or in person appointments for physical or mental health issues
  • They are a normal company seeking profit like all other and today Kry is Europe’s largest digital healthcare provide
  • Kry was founded in 2014 by Fredrik Jung Abbou (founded several start ups) and Johannes Schildt. They wanted to change things for real, address the major societal issues, he has told in Startuppodden. The idea was to build something like Spotify for the health care system, change the conditions 
  • They were a really small player in the beginning because everything was private and private insurance is not really a thing in Sweden. But then they found out about “out-of-county expenses). 

→ Krys’ founder was now aiming for out-of-county benefits, which were sky-high in comparison with other benefits in primary care. They turned to Jönköping, signed an agreement and put their platform there. For each visit of patients who did not live in the Jönköping Region, Kry received upwards of SEK 2,000. Other online doctors followed. This was now partly changed as the payment came down.

  • And just like that Kry does this very often. For more equality between health care providers, since 2019 online doctors would also need to offer physical care in all regions in which they are active. [8]
  • During the pandemic, their business increased significantly!


Positive site:

  • An increasing proportion of distance meetings frees up resources for patients with a more complex need for care. It is good for patients, society and taxpayers, writes Krys Sverigechef Erik Hjelmstedt [10]

→  also offer care in 30 different languages ​​directly and without an interpreter, which often hard at the traditional care centers

→ also have video meetings 24 hours a day, 7 days a year and also available physical care within 24 hours, including weekends and evenings.

→ rigorous medical quality control in real time, and unlike traditional care, our systems alert and correct any errors immediately and allow senior doctors to quickly make knowledge-raising efforts if necessary.

Negative site:

  • They received 50% more compensation than other providers. This is normal to support small providers, but Kry is the biggest in Europe today [7]. This is due to them having two health care centers at one over 13.000 registered and 500 at the other. If you have under 4000 patience you get the 50%. 
  • You can register at Kry if you download the app with basically only one click. Many customers do not understand that once they register there, it is their family doctor care and they automatically unregister from their previous center. This way, KRy got over 10.000 new customers in 4 weeks. As the regions pay per listed patient, this means that Kry gets more money while the health centers that lose patients get less. [8]. 

→ The centers get paid per patient. As other public or smaller private centers have lost patients, they are fearing that they need to cut operations.

→ the critique is, according to Sara Baneges that it is a consequence of Sweden’s care of sickest elderly with many diagnoses and complex needs, such as deep depression and leg ulcers, being underfunded.It is financed by a bunch of patients who come to us sometimes and do not have such great needs. But these are also now the patients which often relocate to Kry, and the other centers lose a fairly large part of our income, but nothing of the care burden.

  • If we look at the data, For “light” patients , the Stockholm Region pays around SEK 1,000 per year. With almost 14,000 listed, Kry can thus receive around SEK 14 million per year, regardless of whether the patients need care or not. For those who seek care, Kry and all other health centers also receive a visit allowance of around SEK 200 per visit. [9]

→ of course, Kry says everyone can come to them. But the digital focus is mainly attractive to the younger population

  • In October, Kry had to change the registration to make it more obvious that patients would change their health center by signing up: “It must not be perceived that listing is a requirement,” writes the Stockholm Region. [11]
  • Kry has also made itself known for its ethically dubious advertising campaigns that encourage unnecessary care consumption. Many of us remember “Hello preschool infections, daycare diseases, autumnal onset and colds. See a doctor within 30 minutes – without leaving home. ” 
  • Another question is data [8]
  • As most is digital, Kry has a bunch of data from its patience. Even though, they enies that the idea is to sell the data, at least right now.
  • “There are no such plans at present. AI and Machine learning will make increasingly important contributions to improving healthcare methods and treatments in the future, and we are of course part of the journey that has only just begun, ”he emails.
  • However, Kry actually already uses artificial intelligence to sort patients into doctors, nurses or self-care.
  • Lina Maria Ellegård points out that Kry is thus building up a large asset: “I think that’s really what drives them. The out-of-county compensation worked for a while. If the Stockholm Region notices that there will be problems, they will probably change something in the regulations. What Kry then has is AI to handle simple patient cases”, she says.
  • Buying 1177 Vårdguiden in Stockholm:
  • The criticism has been loud against Kry’s plans to take over the operation of 1177 Vårdguiden in Stockholm, by buying the company that currently runs the business.[12] 
  • What is the critique? “Of course, one should not be both a caregiver and responsible for the central health care counseling in a region, write doctors Magnus Isacson and Akil Awad.” [13]
  • question of neutrality

Finland

  • Decentralised system that governed at national and local levels. The system will change in the near future due to SOTE- reform that will shift the responsibility from municipilaties to newly created 21 well-being counties.
  • Overall good public health: Life expectancy in Finland (82.2) is higher than average in EU (80.6). It has increased at a faster rate than the EU average. [14] 
  • More than two thirds of Finnish people reported being in good health in 2019 (68 %), a share similar to the EU average. However, the differences bweteen socioeconomic groups are higher than in other Nordic countries. [14]
  • Finland spends less money on healthcare than the EU average, and expenditure also grows slower than in most EU countries. [14]
  • There are three healht care sectors: public, private and occupational health care. These three different systems increase health inequalites, as people from higher socioeconomic groups have access to private and occupational sectors, which facilitate faster access through wider provider choice. [15]

Expenditure

  • In 2019 healthcare expenses were 22 mrd euros, which is 9,2% of GDP. Divided by population this roughly means an estimate of 3980 expenditure euros per person.
    • Biggest expenditure in outpatient care (39%), inpatient care (24%) long term care of the elderely and people with disabilities (17%).  [14]
    • Finland  spends more on prevention per person than EU average.
  • Healthcare expenses were funded mostly by public funding (municipalities, state and Kela) covering 76,8% of all expenses. Private funding covered 23,2 % which is mostly out-of pocket payments. [14]

Parallel health care systems

  • Occupational health care creates a parallel system: it provides quicker and free access for the employed population, while municipal health care users encounter co-payment and waiting times. 
  • Most of the working age population uses occupational health care services that are provided by the employer.
    • 86,4% of working population was covered by occupational health care in 2018, which covers one third of the whole population of Finland. [16]
  • Employers are obliged by law to organize, at the minimum, work-related preventive occupational health care for all employees, such as monitoring of working conditions at the workplace and medical examinations. 
  • Expenses of occupational health care are mainly covered by the employers and through tax-natured payments by all taxpayers. Funding is partly channeled through the National Health Insurance. [16]

Private health care

  • Available for all those who are willing and able to pay high user fees in exchange for quick access, free choice of doctor and practically no gatekeeping.
  • Use of medically necessary private health care is partly subsidized by the state through the National Health Insurance scheme. [15]

Issues

Even though the Finnish healthcare system is based on universality and equity, the health inequalities are rising between socioeconomic groups. Occupational health care and private health insurance (which concern mainly people from higher socioeconomic groups) reinforce inequalities in access to care, as they provide faster access through wider provider choice.  People from lower socioeconomic groups and older people have to wait longer and incur larger co-payments to access services. People with lower income also use less health care services than on average. [15] Biggest issues in Finland’s healthcare are access inequalities, lack of personnel and changing needs of care due to the aging population.

Access inequalities

  • Uneven distribution of resources reinforces disparities in access to care. There is a lack of rescourse especially in rural municiplaties.
  • Public health care has strong gatekeeping: need for care is strictly screened by a nurse at the point of contacting the health centre. Waiting times for non-urgent appointments may be long. Choice of care provider, such as a specific health centre or a certain physician, is limited. Access to a specialist is granted only through a referral from a general practitioner [15].
  • Asylum seekers are not covered by healthcare, as only permanent residents of Finland are eligible. Asylum seekers can receive care trhough rception centers. Undocumented migrants can access urgent care but they might have to cover the costs themselves.[14]
  • The proposed centralisation of health and social care at the regional level

aims to achieve more balanced resource allocation and reduce waiting times.

Unmet medical needs

  • Unmet needs for medical care are reported more often than the EU average and the rate in most other Nordic countries. [14] 
  •  In 2019, almost 5 % of the Finnish population reported unmet medical care needs for financial reasons, geographical barriers or waiting times, compared to below 2 % on average across the EU. 
  • By far the main reason reported was waiting times. The proportion of people reporting unmet needs for medical care in the lowest income quintile was almost twice that in the highest. [14] 
  • 81% of the highest income group reported being in good health while only 54% of the lowest income group reported this.[14]

Aging population

  • Finland is one of the most rapidly ageing societies and forecasts predict that one in seven Finns will have reached the age of 75 by 2030. [17]
  • Aging population increases the need for care, as simultaneously the life expectancy increases -> older people have more care needs and disabilites.
    • Functional limitations in 65+ age group are experienced by 48,5%. [19]
  • Increase in for-profit long-term care providers in elder care since 1990s 
    • To highlight this shift towards privatisation: only 21% of people aged over 75 received publicly funded healthcare in 1990 compared to 30% in 2019. [18] 

Care poverty

  • Care poverty means the inedaquate coverage of care and it is mostly experineced by the elderly population
    • 26% of people over the age of 75 do not receive adequate care with their daily needs and one in six (17%) in everyday necessities. [18] 
    • Age restrictions to disability services, disabilities and limitations are considered “natural” and age-related. Memory impairments are excluded and not considered as disability and therefore people with memory impairments are not eligible for disability services. [19]

Shortage of available personnel 

  • Finland has fewer doctors than the EU average (3.2. per 1000 compared to 3.8), but the highest number of nurses (14.3 compared to 8.9.) [16]. 
  • Over the next ten years, a large number of municipal social welfare and health care personnel will retire. At worst, the percentage in the regions will reach almost 40%.[17] 
  • Lack of personnel will increase the regional differences in access to healhtcare: most of the aging population lives in rural municipalities, where it is increasingly difficult to hire employees.
  • The growing challenge of the service system is that the availability of health care personnel is becoming more difficult in an increasing number of professional groups. For example, the development of the personnel structure of services for elderly people has not fully followed the change in the service structure.[14]
  • The lack of senior specialists in mental health is also common. In particular, there is a shortage of psychiatrists, psychologists and psychotherapists.[14]

Sources: 

[1]https://healthmanagement.org/c/cardio/issuearticle/overview-of-the-healthcare-systems-in-the-nordic-countries

[2] https://nordics.info/show/artikel/healthcare-in-the-nordic-region/ 

[3] www.euro.who.int%2F__data%2Fassets%2Fpdf_file%2F0011%2F98417%2FE93429.pdf 

[4] https://www.thelocal.se/20140505/sweden-has-third-lowest-child-death-rate/ 

[5] https://www.ucl.ac.uk/news/2018/may/why-child-mortality-15-times-higher-england-sweden 

[6] https://www.thelocal.se/20210828/discrimination-against-foreign-doctors-widespread-in-sweden/

[7] https://www.svd.se/stockholm-ger-kry-extra-betalt-for-digitala-besok

[8] https://www.svd.se/krys-succeaffar–att-hitta-kryphal-i-systemen 

[9] https://www.svd.se/166-vardcentraler-har-forlorat-listade-patienter 

[10] https://www.svd.se/kry-vi-tar-helhetsansvar–det-gynnar-patienterna

[11] https://www.aftonbladet.se/nyheter/a/6zjXz8/efter-kritiken-mot-kry–sa-skarps-reglerna 

[12] https://tidningensyre.se/2021/18-januari-2021/efter-kry-kritiken-nu-far-politikerna-bestamma/ 

[13] https://www.dagensmedicin.se/opinion/debatt/stoppa-forsaljningen-av-1177-till-kry/ 

[14] https://ec.europa.eu/health/system/files/2021-12/2021_chp_fi_english.pdf 

[15]  https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0231792 

[16] https://www.tyoelamatieto.fi/fi/articles/analysisOhsCosts

[17] https://www.julkari.fi/bitstream/handle/10024/142741/URN_ISBN_978-952-343-684-8.pdf?sequence=1&isAllowed=y 

[18] https://www.ingentaconnect.com/content/tpp/ijcc/2019/00000003/00000004/art00002?crawler=true&mimetype=application/pdf 

[19] https://www.sciencedirect.com/science/article/pii/S0890406521000438 

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