As an American physician living in Sweden for the past year, I’ve had the opportunity to compare the healthcare systems from a parent, clinician, and entrepreneur’s point of view. The experience has been fascinating, and opened my eyes to a number of innovations that could be of great value back in the US.
In many ways (at least in theory) Sweden represents the ideal of what US advocates for Value Based Healthcare see as the framework for an ideal healthcare system. As each region serves as a single payer for its inhabitants, cost awareness is a necessity for managing the limited tax-revenue available for healthcare. An extensive system of clinical registries, famous around the world in research circles, enables insight into quality through national benchmarking. A proliferation of consumer-oriented digital technologies and public-private partnerships have opened up access to care recently, which is traditionally a weak point of single payer systems. And while the system doesn’t always live up to its promise (which I will cover in my next post, on What Swedish Healthcare can learn from the US), there are some key principles the US could learn from to fix our ailing healthcare system.
Make digital easy and normal: In non-healthcare settings, Sweden is acknowledged as one of the world’ most digital societies, on route to be coming the world’s first cashless society, as well as the home of music streaming and a leader in e-government. A well-developed digital identification and payments infrastructure has laid the groundwork for an explosion in digital services, with companies like Kry, Doktor24, and doktor.se driving telemedicine use rates 10x what we’re seeing in the US, and creating great profit for investors. The largest private primary care chain lets you text a doctor 14-hours a day, 7-days a week, using a system built by a Stockholm-based startup. Government hospitals don’t have as beautiful tech-interfaces as the VC-backed startups, but are not far behind. When a family member suffered a heart attack and was treated at the (state-run) teaching hospital, I was able (with her permission) to login through a secure portal and read her medical journal, including cath-lab results and progress notes, in real-time. After spending over a billion dollars on a new medical record, my old US hospital system can’t do anything like this. While system interoperability is not much better than the US, the quality registries I mentioned above allow national-level insight into how different regions and providers are faring in areas from diabetes to spine surgery. Some of the most innovative companies (like Era Health) are further integrating this data into dashboards that allow individual clinics and doctors to measure (and improve) their performance in real-time.
Using common sense is OK: The fear of litigation has rendered much of American medicine unable to utilize basic common sense. About 1/4 of US ED patients are sent to the Emergency Department by their primary care doctor — quite often for runny noses, fevers, or high blood sugars that can be managed better (and cheaper) in a primary care office. The fear that “something bad could happen” drives American doctors to default to the “safest” (and usually most invasive expensive) option. Whether it descends from a tradition of Viking stoicism, or just limited resources from state funded healthcare, Swedish health policy and care pathways formalize the concept of “egenvård” — literally, self-care, which is ALWAYS the first step in managing a health issue. It’s ironic that socialist Sweden push self-reliance, whereas aspects of the capitalist US system try to infantilize patients into thinking they need an ambulance for every sniffle.
Healthcare and social services are different (but both necessary): Over the past few years, the US healthcare system has had an epiphany around the “social determinants of health,” realizing that when people are poor and don’t have access to good nutrition, exercise and housing, they get sick, and dedicating resources and personnel to addressing these underlying issues. This is great, but healthcare systems (and hospitals particularly) are expensive, poorly connected to local communities, and slow bureaucratic decision makers. Hospitals are the costliest and most cumbersome institutions you could imagine for this role. Sweden (like most other developed countries) realized that social problems are worth addressing around 100 years ago, and developed a robust non-medical social services system that works to make sure that people have access to a minimum standard of housing, food, security and preventive care. For cultural reasons, Americans hate the idea of government spending on “welfare,” but are willing to spend double the cost when it’s branded as “healthcare,” consistently spending more to get less.
But as I mentioned above, Swedish healthcare in practice often falls short of the ideal. Patients face significant challenges accessing specialty care, and quality of care is not as consistent as the egalitarian society would like it to be. More on this in next week’s article, What Swedish Healthcare can learn from the US.