Internal market systems in Sweden: seven years after the Stockholm model

Sweden, like other European countries in the 1990s introduced internal market reforms in the delivery of health care. Specifically, in Stockholm county, the Stockholm model was introduced to strengthen the position of patients in their choice of care. Other reform measures introduced included the family doctor's legislation, care guarantee and the adel reform. This paper reports interviews with Swedish physicians, politicians and health economists seven years after the introduction of these reforms. The broader goals of this paper are to explore the extent to which these changes have overtime affected the views of physicians as they reflect on their working conditions and experiences with the use of the diagnostic-related groups (DRG) system.

Data was obtained from in-depth interviews of 15 primary care physicians, 4 heads of hospital departments (surgery), 5 county council members and 4 health economists (N = 28). A content analysis was performed on major themes on the interview transcripts.

The majority of our respondents reported that the financial incentives introduced through performance-based reimbursements do exist in Stockholm county and that productivity and efficiency have increased over the period of investigation. Primary physicians voiced support for the privatization process in health care delivery. Most physicians reported that they were generally satisfied with their work. Over half of the general physicians complained about their working conditions but felt they have a unique way to play as 'gatekeepers' in the overall Swedish health care delivery system.

Our findings suggest that physicians are generally satisfied with their working conditions. Over 90% of our respondents support the use of a diagnostic-related group. What is clear though is that the primary care physician's role due to its potential benefit as an agent of cost control is important, but it is not clear that the primary care physicians have made a major contribution to the Swedish health care delivery system as they should be.