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Sweden makes move toward increasingly fewer hospital beds, more outpatient surgery
Reimbursement policies have driven the increase in private practice procedures.
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Sweden has drastically reduced hospital beds in ophthalmology departments. The capital city, Stockholm, hosts St. Erik Eye Hospital, the only specialized eye hospital in the country. Here, beds have been cut from 90 in 1980 to 16 now, and further cuts of two additional units have been planned.
Stefan Seregard, MD, PhD, chairman of the Department of Vitreoretinal Diseases at St. Erik, sees this as a positive move.
“We don’t need many beds in ophthalmology. Most of our procedures can be done in outpatient settings,” he said.
Stockholm’s metropolitan area is home to 2.4 million people, about one-quarter of the country’s population. Approximately 23,000 cataract surgeries are performed per year, again about one-quarter of the 115,000 performed nationally. Only 4,000 of them are done in public services, while the majority — 19,000 procedures — are performed in private practices. Conversely, all retinal surgeries, approximately 3,000 per year, are performed in public services, and so are virtually all intravitreal injections, 14,000 in 2015.
“The reason why 82% of cataract surgeries are performed in private practices while 100% of retinal procedures are done at the hospital is that cataract surgery is reimbursed in private practices. In addition, co-payment is allowed there for multifocal and toric IOLs,” Seregard said.
All retinal procedures are otherwise reimbursed in hospitals, but those who may need general anesthesia and/or hospital beds are mainly retinal detachment cases. Basically, out of the 200,000 patient visits per year at St. Erik, there are only 1,600 admissions, mostly for retinal detachment.
“If we add to this the 250,000 visits per year in private practices and another 30,000 at the Söder Hospital, which provides some eye care but no hospitalization, admissions are a very small percentage,” Seregard said.
A high investment in health care
“Sweden has a system of decentralized socialized medicine, meaning that it is basically all public medicine. Even if you are in private practice, you will be reimbursed by the county council. Individual patients only contribute 200 to 300 crowns, the equivalent of 20 to 30 euros per procedure,” Seregard explained.
There are 21 counties in Sweden, quite diverse in terms of population and services offered. Some, in the more urbanized south, have a population of more than 2 million, like Stockholm, while northern counties cover large areas of sparsely populated land with no more than 150,000 inhabitants.
“It is quite difficult to get these 21 health care districts to cooperate and there has been a lot of discussion about merging them into six regions, but it doesn’t look as this is going to happen any time soon,” Seregard said.
However, although each county council has an independent tax system, 90% of council taxes are used for health care.
Reimbursement is key
Taking a broader look at Europe and comparing Sweden with countries with the same GDP per capita, such as Austria and Germany, a similar number of ophthalmologists and comparable health care expenditure, the difference in number of hospital beds is quite striking.
“Basically, this is down to the reimbursement system. If you are reimbursed for the number of hospital beds, you will try to keep or increase the number of hospital beds and in-patient procedures. If you are reimbursed for the procedure, the tendency will be to cut down on the number of hospital beds and do as many procedures out of the hospital as possible,” Seregard said.
Reimbursement has driven ophthalmologists in Sweden to do most cataract procedures in private practices, while in other countries in Europe, due to lack of reimbursement, a substantial proportion of cases — about half — are still done as inpatient procedures. This occurs even though statistics show comparable results in and out of the hospital.
“For the same reason, some procedures like phacovitrectomy are not done at our hospital because we are not reimbursed for two procedures but only for the more expensive of the two. Financially, it would be a disaster to do them in the same session,” Seregard said.
At the end of the day, it all comes down to the money, he said. The reimbursement system, not the actual need for medical purposes, drives and determines the number of hospital beds.
“We might have gone even too far with this in Sweden and might decide to slightly increase the number of beds in the next few years, but this is for other specialties that need them, such as internal medicine or surgery, not for ophthalmology,” Seregard said. – by Michela Cimberle
- For more information:
- Stefan Seregard, MD, PhD, an OSN Europe Edition Board Member, can be reached at St Erik Eye Hospital, Karolinska Institutet, Polhemsgatan 50, SE 11282 Stockholm, Sweden; email: stefan.seregard@sll.se.
Disclosure: Seregard reports no relevant financial disclosures.