SOCIAL INSURANCE

The key to the ability of the Swedes to provide equitable inpatient and outpatient services is equitable financing. Inpatient services are financed almost entirely through taxes. Outpatient expenses are financed through a comprehensive social insurance scheme, with premium determined on a progressive scale. National health insurance in Sweden was created in 1955. In 1963 health insurance and pensions were combined into a single National Insurance Act. It is from the fund created by this Act that most out-of-hospital medical expenses in Sweden are paid.

The National insurance system is currently administered by twentysix regional offices. The National Social Insurances Board retains the right to manage and inspect the regional offices. Grievances against the regional board may be taken to the National board or to the National Social Insurance Court, which is the court of final appeal in insurance

cases.

Benefits under Swedish national health insurance include payments made in connection with treatment by a doctor, a dental surgeon and at a hospital. They also include the costs of medically related travel and subsidy for needed drugs.

At present, they include full payment, except for about $1.60, to publicly employed physicians. Private practitioners may charge whatever they wish, and are reimbursed 75 percent of a standard fee schedule, with the patient paying the remainder.

In addition, sickness insurance provides for a "sickness benefit," or benefit in lieu of lost wages. It is designed to reimburse the patient for about 80 percent of lost income. The basic sickness benefit (the minimum paid) is about 6 Sw Kr (about 85 cents) per day. The maximum paid is 52 Sw Kr (about $7.50) per day. For the first time in Swedish history, no meaningful monetary transaction between doctor and patient takes place, and almost all physicians are on the government payroll. This reform is currently under vigorous debate within the Swedish medical community, with Swedish physicians and the Swedish Medical Association in opposition to the government-sponsored reform. (See the article by Professor Gunnar Biorck, Appendix 3.)

PHYSICIAN DISTRIBUTION

An equitable system of financing health services is one prerequisite to the achievement of true equity. Another is the equitable distribution of services. Serious problems of maldistribution of health care facilities and personnel exist in the United States. Large rural areas exist in which no physicians are willing to locate. Sweden is almost 1,000 miles long, and also contains vast stretches of rural and isolated land. Much of the country lies above the Arctic Circle and is sparsely populated. Problems in the provision of health care to rural areas exist and are serious in Norway, Sweden and Finland. The Subcommittee visited northern Sweden in order to study ways of dealing with health care distribution problems in rural areas, and possibly to see solutions to these problems which may be suggested solutions to the problems in

In Sweden, as in the other Scandinavian countries, one of the responsibilities of the various county councils is the appointment of district health officers. In Sweden's nonurban areas, one district health officer per 6,000 inhabitants is required by law. This legal minimum cannot always be fulfilled due to manpower shortages. At present, there are about 1,000 medical officers employed by the county councils, serv ing approximately 500 rural districts. Each district health officer has public health, administrative, and general practice duties. County councils compete among themselves for district health officers.

Various inducements exist in order to attract other physicians to rural areas. Funds for travel to professional meetings and for postgraduate medical education, as well as opportunities for sabbaticals at [ one of Sweden's University medical centers are provided more readily for rural than for urban physicians. Subsidized housing is often provided.

Another important element in this attempt to induce physicians to locate in rural areas is the relationship of the district hospitals to the medical schools.

All publicly-owned hospitals are subject to evaluation and contro! by the county councils and the National Board of Health and Wel fare. Problems related to uniformity of services and hospital standard can, therefore, be dealt with directly.

All public hospitals in Sweden are accredited by the Board of Health and Welfare as teaching institutions. The immediate impact of this arrangement is to enable even the smallest and most remote hospitals in Sweden to attract young physicians still engaged in their internships and residencies. All Swedish physicians are required to go through a twenty-one month period of training following their graduation from medical eschool. Many Swedish graduates, as well as some graduates from other European medical schools, serve their obligatory period in a rural area.

Some remain in rural areas as general practitioners after the com pletion of their training. This arrangement appears to do much to relieve the sense of isolation which rural physicians in the United States compain about.

Despite these features, there remains a rather serious shortage of physicians in rural areas. However, no large gaps in geographic coverage exist in Sweden, as they do in the United States.

TOTAL COSTS

Expenditures for health care and social welfare benefiists in Sweden. comprise approximately 28 percent of total governmental expenditures and 5.5 percent of the gross national product as of 1968-69.

(For other aspects of Medical Care in Sweden, see Appendices 4 and 5.)

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HEALTH CARE IN NORWAY

HOSPITAL REGIONALIZATION

The long Scandinavian history of local or communal responsibility for providing hospital beds has led to a strongly hospital oriented health care system in Norway, as in Sweden. The overall ratio of beds to population is 9.4 per 1000. 85 Percent of these are owned and operated by the public sector. The ratio of beds per population designed to care for somatic (excluding mental) illness is 7.0 per thousand. Of these, 5.0 per 1,000 are general hospital beds.

The average length of stay in Norwegian general hospitals is 15.5 days. This compares with a range length of 5.3 to 10.5 days in the United States. Norway has 368 hospitals housing 34,500 beds.

In the past, Norway's hospitals have tended to be relatively small, and to serve a limited geographic area. The limited capability for the transport of sick patients has contributed heavily to the development of this particular pattern of hospital regionalization in the past. In more recent years, however, it has become possible to design hospitals which cover a larger geographic region.

Regionalization of hospital services is based upon the concept of centralization of those services which are highly specialized, unusually expensive, or short in supply. Regionalization is based upon four types of hospitals.

The smallest is the local cottage hospital, which is really a dispensary, having from eight to twenty beds. Patients are kept in these hospitals primarily for observation. For that reason, they tend to be located in sparsely populated or remote areas, where access to adequate home health services is limited. Norway has about 100 such cottage hospitals.

The next largest-size hospital is the local hospital. These hospitals all contain departments of internal medicine, surgery and radiology, and have between 45 and 200 beds.

The central hospital is designed to meet the hospitalization needs of a single province. It contains departments of surgery, internal medicine, radiology, neurology, ENT, pediatrics, gynecology, obstetrics and psychiatry. The bed complement ranges from 250 to about

700.

The regional hospital is the largest and most sophisticated of the Norwegian hospitals. They contain, in addition to basic services, highly specialized services such as radiotherapy, neurosurgery, thoracic surgery, plastic surgery and pediatric surgery. Regional hospitals are affiliated with one of the two Norwegian medical schools

Hospitals the size of local hospitals or larger have out patient departments, and provide service by referral to the patients of general practitioners, and provide a major source of the specialty care in many communities.

A distinct trend toward phasing out specialty hospitals, such as cancer hospitals or tuberculosis hospitals exists in Norway.

HOSPITAL STAFFING

The large majority of physicians working in hospitals are full time. salaried employees. All physicians working in hospitals are appointed by the Director-General of Health Services, who has full responsibility for appointment of the most qualified applicants. He has the system of consulting with the Medical Association if he so desires.

HOSPITAL-BASED EDUCATION

Norwegian hospitals also participate in the training of medical students (1 year mandatory service) and residents.

HOSPITAL FINANCING

Hospitals for Tuberculosis and mental diseases, and the University Clinics are funded by the National Government. By tradition, the local communes have had the responsibility for supporting hospitals As hospital cases have increased over the years, however, the extent of state involvement has increased.

On January 1, 1970, a law was implemented which had the effect of providing coverage of 85 percent of approved operating costs under the health insurance organizations. Fifteen percent of expenses will be covered by the commune or, in the case of private hospitals, the owner.

The costs of education may be included in the approved costs submitted to the insurance organization.

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SOCIAL INSURANCE IN NORWAY

Social insurance in Norway, as in the other Scandinavian countries, is extensive. It has developed slowly, beginning with limited coverage for specific and limited population groups, has gradually grown to include comprehensive, universal services.

Health insurance in Norway came into effect in 1911, covering only low-income groups. Over the years, health insurance has evolved until it is now universal (coverage for everybody in Norway) and compulsory. In 1967, a national health insurance law was adopted. Since then, a process of consolidation of the individual insurance coverages has been occurring.

RANGE OF BENEFITS

Norwegian national health insurance currently includes coverage for medical consultation, or visit by a doctor, and all hospital treatment in public hospitals, but only limited coverage in private hospitals; the costs of maternity services are covered; compensation for lost income during maternity leaves and rehabilitation following occupational illness or injuries are also covered services. In addition, a host of other social benefits are provided.

Of great relevance to the debate in the United States is the fact that the Norwegian Medical Association has recognized the need for cooperation with the government and have been most suportive of the national health insurance concept from the outset.

THE NORWEGIAN MEDICAL ASSOCIATION AND HEALTH INSURANCE

Norway, like Sweden, has a long tradition of societal responsibility to the individual in need. This tradition is reflected by heavy government involvement in social services, including health. Despite this, it has been possible for the Norwegian Medical Association to develop a cooperative relationship with the government. As a result of mutual respect and cooperation throughout the years, relative freedom of choice on the part of physicians and patients (as compared with Sweden) has been retained in Norway.

Ninety-five percent of all Norwegian physicians belong to the Norwegian Medical Association. The Association functions, in many ways, as a true peer review group. They concern themselves with matters of physician compensation, utilization of services, and ethical behavior. Sanctions are brought to bear upon physicians who are guilty of violations of conduct in any of these areas by the Medical Association.

Four principles form the policy basis of the Norwegian Medical Association.

1. The Association believes in free choice of physician by the patient.