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European Observatory on Health Systems and Policies

Sweden


Health Systems in Transition (HiT) profile of Sweden

3.4 Out-of-pocket payments

Private expenditures as a proportion of total expenditures on health accounted for about 17% in 2009, where 93% were OOP payments (Table3.1).

3.4.1 Cost-sharing (user charges)

There are direct user charges for health care visits in both primary and specialist care in the form of flat-rate payments. In 2009, the county councils received SEK 6186 million (€687 million) in patients’ fees and other fees (with SEK 2781 million (€309 million) for dental care), which accounted for 2.4% of the county councils’ total revenues. County councils determine the level of the user charges for primary and hospital care.

In 2011, the fee for consulting a physician in primary care varied between SEK 100 (€11) and SEK 200 (€22) across the county councils. The fee for consulting a specialist at a hospital varied between SEK 230 (€25) and SEK 320 (€35) the same year (see Table3.5). In almost all county councils, children and young people (under 20 years of age) are exempt from patient fees for health care as well as for dental care. At primary care clinics, vaccinations, health examinations and consultations, and certain types of treatment are provided free of charge to all children of school age. At the ante-natal primary care clinics, regular check-ups are given free of charge during the entire pregnancy. User charges for inpatient care are separate from other user charges. Patients above 20 years of age are charged about SEK 80 (€9) per day of hospitalization with some minor differences across county councils.

User charges for prescription drugs and dental care and high-cost protection schemes for health care visits are regulated by national law. The national ceiling for OOP payments regulates the maximum amount that an individual will pay within a period of 12 months. From January 2012, the national ceiling for OOP payments for health care visits is SEK 1100 (€122). When the cost ceiling has been reached, the patient pays no further charges for the remainder of the 12-month period, calculated from the date of the patient’s first visit to a physician. In practice, the ceiling constitutes a restriction on the county council fee revenues.

The ceiling for individual co-payments for prescribed drugs is separated from the other health care services and is administered by the TLV. Co-payments for prescribed drugs are uniform throughout the country. The patient has to pay the full cost for prescribed drugs, up to SEK 1100 (€122), after which level the subsidy gradually increases up to a 100%. The patient pays 50% of the cost between SEK 1101–2100 (€122–233), 25% of the cost between SEK 2100–3900 (€233–433) and 10% of the cost between SEK 3900–5400 (€433–600). Within a 12-month period, the maximum co-payment is SEK 2200 (€244) for prescribed drugs. For a household, all children are covered by the same high-cost protection scheme for prescription drugs, that is, SEK 2200 (€244) maximum for all children within the same household during a 12-month period. The ceiling for patients’ fees for medical devices is SEK 2000 (€220). In practice, the ceiling constitutes a restriction on the county council fee revenues. County councils receive designated prospectively decided state grants for subsidies for prescription drugs.

Since the dental care reforms in 1999, 2002 and 2008 (see section 6.1.6 Changes in subsidies and co-payments for pharmaceuticals and dental services) there are two types of subsidies for dental services. A fixed general annual subsidy is paid for preventive dental care and general examination of SEK 300 (€33) for people aged 20–29 years, SEK 150 (€16) for people aged 30–74 years and SEK 300 for people aged 75 years and over. For other dental care services, there is a separate high-cost protection scheme for each 12-month period. Patients pay the full cost up to SEK 3000 (€333) and then get the following subsidy: 50% of costs for services with a price between SEK 3000 and 15 000 (€1667) and 85% of costs for services with a price above SEK 15 000 (€1670). In contrast to outpatient visits and prescription drugs, there is no absolute cap on user charges for dental care. The subsidies for dental care are included in national health insurance, and financed by the Swedish Social Insurance Board. The subsidies subject to the high-cost protection scheme are based on reference prices determined by the TLV. There is price competition between dentists. Should they demand a higher price for a certain service than the reference price determined by the TLV, patients have to pay the difference between the reference price and the price charged by the dentist out of pocket (not included in high-cost protection scheme).

With regard to services for older and disabled people there is a separate maximum co-payments fee for services provided in the municipal sector (see section 5.8). In 2011, the maximum fee was SEK 1712 (€190) per month (see section 6.1.6 Changes in subsidies and co-payments for pharmaceuticals and dental services).

The size of patient fees as a proportion of total costs have been fairly stable during the past decade for both primary and hospital care as well as for pharmaceuticals (Table3.6). A downward trend can be observed for dental care, however, following the reforms during the late 1990s and 2000s.

In the budget bill for 2016, the Swedish government proposed that contraceptives should be offered free of charge to young people under the age of 21 for products included in the pharmaceutical benefits scheme. The new legislation entered into force in 2017 and is under implementation and evaluation. The aim of the reform is to reduce Sweden's rate of unwanted pregnancies and abortions. According to the Swedish government, availability of free contraceptives can be effective in reducing unwanted pregnancies, especially among groups with lower socioeconomic status.

The county councils are still free to subsidise contraceptives that are not included in the pharmaceutical benefits scheme, therefore the price varies for some contraceptive types and brands. Some county councils subsidize contraceptives for larger groups, e.g. young people under the age of 25.

References
Health care and Social care. Proposals for the state budget. In the Budget Bill for 2016, prop. 2015/16:1 (in Swedish): https://www.regeringen.se/4a9bb0/contentassets/49618bcb4fd94b6081d9696f55bc7f8d/utgiftsomrade-9-halsovard-sjukvard-och-social-omsorg.pdf

Ds 2015: 59 Special investments in the health of young people and the elderly (in Swedish) https://www.regeringen.se/4af7f7/contentassets/ee9477d0121045b9996534c35ab0adfd/sarskilda-satsningar-pa-ungas-och-aldres-halsa-ds2015_59.pdf 

In May 2016, the Swedish parliament approved a government bill proposing legislation for free mammography screening for women aged 40-74 years. The new legislation entered into force in July 2016 and is under implementation and evaluation. The aim of the reform is to increase participation in mammography screening, especially among women with a low socioeconomic status.
 
In accordance with a recommendation from the National Board of health and Welfare (Socialstyrelsen), all county councils invite women aged 40-74 years to mammography screening with an interval of 18-24 months. Prior to the reform, county councils were free to collect patient fees for screening and the fee varied between county councils. The government compensates county councils for the increased costs associated with the reform via the general government grant to the county councils.

References
Government proposal 2015/16:138 (in Swedish):
https://www.regeringen.se/49547d/contentassets/1f09b6e0fc0549c5ae26309506a8b4b5/avgiftsfrihet-for-viss-screening-inom-halso--och-sjukvarden-prop-201516138.pdf

Recommendations on screening for breast cancer from The National Board of health and welfare (in Swedish):
https://www.socialstyrelsen.se/regler-och-riktlinjer/nationella-screeningprogram/slutliga-rekommendationer/brostcancer/ 

In the budget bill for 2017, the government proposed that outpatient care (within the scope of the high-cost protection scheme) should be without charge for people age 85 and above. The main aim was to improve health among older people. Despite the existing high-cost protection scheme, the government considered that the costs for various and repeated health care visits can be an economic burden for older people in need of health care.

Because the county councils are responsible for health care delivery and also collect patient fees, the change, which took effect on 1 January 2017, would have an economic impact on the county councils. The government would therefore compensate the county councils for the economic burden via the general government grant regularly paid from the government to the county councils.

References
Prop. 2016/17:1 Budget Bill for 2017 (Headings 9 p54; 25 p9,32-34) (in Swedish)

Health care and Social care (2017) Proposals for the state budget (in Swedish)(https://www.regeringen.se/4a6bd5/contentassets/e926a751d9eb4c978c4d892c659ebc8e/utgiftsomrade-9-halsovard-sjukvard-och-social-omsorg, accessed 28 Nov 2018)

General contributions to municipalities (2017) Proposals for the state budget (in Swedish) (https://www.regeringen.se/4a6bc0/contentassets/e926a751d9eb4c978c4d892c659ebc8e/utgiftsomrade-25-allmanna-bidrag-till-kommuner, accessed 28 Nov 2018)