Decentralized responsibility for costs of outpatient prescription pharmaceuticals in Sweden. Assessment of models for decentralized financing of subsidies from a management perspective.

In this study, models for decentralization of responsibility for costs of subsidised outpatient prescription pharmaceuticals within the county councils in Sweden were studied. The aims of the decentralization were to cut the escalating costs associated with risk sharing mechanisms on a national level and to integrate utilization of drugs into the priority process in health care. History of development and the characteristics of the solutions on county level were identified, described and analysed from taped interviews with relevant persons in central management positions in the selected counties. Information was supplemented from documentation. Two main models were found, a population based model and a prescriber based. In the population based model, family medicine in primary care was responsible for subsidies of drugs classified as "basic" (80%) regardless of prescriber. In this model, hospital departments were responsible for the "special" drugs (20%) regardless of prescriber. In the prescriber based model each provider was responsible for costs of its own prescribing. We found that the prescriber based model was chosen for the strong incentives for cost containment, while the population based model was expected to focus more on service to patients. This reform was based on the assumption that incentives for cost containment on an organisational level are effective. Experiences from other reforms in health care support this hypothesis. This means that there is a risk that cost containment jeopardises medical decisions on patient level.