One concern arising from the market developments introduced in long-term care is that competition may have contributed to a further fragmentation of care provision. As a consequence, users, many of which are in a vulnerable situation now have to navigate an even more complex system of providers to address their needs of health and social care. At the same time, integrated care provision may rest on the concentration or at least coordination of several providers, thus negating possible benefits arising from competition (production efficiency) and choice (allocative efficiency). Policy makers may thus face a conundrum when pursuing policies that simultaneous aim to integrated care and increase choice and competition.
This study set out to investigate whether choice and competition are compatible with integrated care and if not, what are the consequences for users?
For this purpose, a comparative research approach was chosen to analyse differences within and between countries, namely in selected municipalities in Sweden (Norrtälje) and Germany (Dortmund and Leipzig). Germany was chosen as a comparator for Sweden because it represents arguably the most market-oriented governance of long-term care system in Europe, a highly diverse provider market due to relative low barriers to entry, and a high level of user choice based on a mix of benefits in cash and in kind.
Fieldwork for this project (semi-structured expert interviews) took place between October 2014 and March 2015. The final report (August 2015) provides, first, an overview of theoretical considerations concerning the compatibility of choice and competition with integrated care as well as definitions of key concepts. Following the presentation of general framework conditions of health and long-term care systems in Sweden and Germany, and the presentation of the selected sites of case studies, the most important findings from expert-interviews are conferred in a comparative perspective. Finally, the discussion of findings leads to general conclusions and potential opportunities for mutual learning.
The findings of this qualitative study showed a nuanced picture as to the potential conciliation of choice and competition, and integrated care. The overall opinion of those interviewed in the three sites was that it was possible to achieve integrated care in a context of user choice and competition. For many of the different stakeholders interviewed – particularly in Germany – user choice had been internalised as a de facto right of users. Integrated care initiatives in the German sites are thus forced to work in a context of choice and competition, in some cases they even were a reaction to this basic framework condition, while in the Swedish site, competition became a new challenge for an already established integrated care model.
Apart from the well-known barriers to cooperation (lack of information, time, incentives, and trust), a number of coping strategies could be identified that actually enhance collaboration, e.g. to draw on other providers to supplement one’s own services or to channel users to partners in the network that would be more suitable to deal with particular needs. This process of ‘enlightenment’ towards voluntary cooperation seems still to be an on-going process in Germany, while in Norrtälje new providers that appeared in the context of the newly introduced customer choice model complemented the already existing integrated care model in 2008 have to work within predefined integrated structures and processes. Both in Swedish and German sites there is, however, fierce competition for appropriate staff, and it seems that this type of competition is often more detrimental to cooperation than competition for clients, in particular under conditions of undersupply.
While direct comparisons between the three sites should be considered with caution, given the underlying governance differences between the German and Swedish health and long-term care systems as well as the differences in size as well as the degree of integration between the three study sites, there are however a number of salient lessons and recommendations arising from this study that are liable to be applicable to other contexts.
This study has shown that current ways of funding in ‘silos’ based on fee-for-service payments remain an important barrier for collaboration. As all providers are chiefly driven by chasing for clients or service hours within a taylorised system of professionally divided tasks, general aims such as social and individual well-being often get out of sight. Under conditions of market-oriented governance the challenge is therefore to find new ways to use those aspects of positive dynamics of competition that have been identified in this study to enhance vertical and horizontal collaboration in long-term care by means of appropriate financial and professional incentives.