Ten years experience with models for financing of outpatient prescriptions

•Financial responsibility for outpatients' drugs was decentralised in Sweden in 2002.•Implementation in 9 counties – early adopters – were studied 2003 and 2012.•Two main models were found; the population based and the prescriber based.•The local financial responsibility for pharmaceuticals has strengthened over time.•Evidence for incentives for cost containment on organisational level were found.

BackgroundRisk sharing mechanisms in health care balance between need and demand within the financial limits, acceptable from medical, political and ethical perspectives. Subsidising outpatients' medicines is part of the risk sharing. In order to stimulate a more cost-effective use of resources decentralisation of the financial responsibility for pharmaceuticals was introduced in Sweden in 2002. In this study we explored the development 10 years after the implementation.MethodThe Swedish counties are responsible for all financing and provision of health care. In this study nine representative counties were included, each with its own set of models for devolution of financial responsibilities. Information was collected from written sources and supplemented by interviews with high level officials and administrators in each county.ResultsTwo main models were found; in the population based model the responsibility for subsidising pharmaceuticals is decentralised to the primary care units and their responsibility follows listed patients regardless of prescriber. In the other model each prescriber is financially responsible for own prescribing. In addition, over time mixed models were developed.ConclusionsIncentives for cost containment on an organisational level seem to be highly effective although there is no individual economic return involved. The prescriber based model seems to be more robust in terms of capping costs while the population based includes a higher level of service to the patient. The choices of principles were based on norms and responses from the users, and were not actively assessed by the counties in terms of cost efficiency.