Under the concept of eHealth, a large number of different types of digital innovations for health and medical care are found, including those for diagnostics, information management, and communication. Development in the field of eHealth and related services is progressing rapidly and will most likely continue to affect current health care systems in various ways. In particular, these technical developments have led to a simultaneous increase in the expectation that they will lead to significant efficiency gains and reductions in overall health spending. In 2005, the RAND Corporation suggested that the introduction of health information technologies, such as electronic health records, could save the US health system around US$81 billion per year in efficiency gains [1]. The study also identified additional cost savings twice as large from the broad introduction of health information technologies to prevent and manage chronic diseases in the USA. More recently, other stakeholders have made similar claims. For example, Goldman Sachs suggests that around US$300 billion could be saved from such investments in the US health system [2].
In Europe, the European Commission and other organizations point to large expenditure savings from the introduction of various types of eHealth technologies [3]. Focusing on the Swedish health care system, McKinsey finds that savings of around 180 billion Swedish krona (SEK) (equivalent to approximately US$20 billion as of February 2017) per year could be accomplished through the implementation of various types of eHealth solutions [4]. Similarly, PWC suggests that the Swedish health system could save around SEK1.2 billion (US$136 million) per year if one in ten primary care visits is made over the Internet instead of at a traditional clinic [5].
However, the evidence base for these claims is relatively small and of varying quality and not many have analyzed the cost impacts in any systematic manner [6, 7]. One decade on from the RAND study, the significant efficiency gains from various types of eHealth technologies do not appear to have been realized [8, 9]. The reasons for these failings include weak uptake of and adaption to new technologies, poor design of innovations, and costly technologies in terms of purchase and maintenance.
While many digital solutions replace existing analog systems, one innovation with potentially large impacts on the health care system is the ability to provide services over the Internet. By means of telehealth, patients are able to consult with a health care provider without the need for and associated costs of an in-office visit. During a digital consultation, the patient describes his or her symptoms and the ‘visit’ results in one of several outcomes: no further measures; general or specific advice; prescription for medicine; referral to another provider, or further laboratory testing or scans. These outcomes overlap with most of those of an office-based primary care consultation. Given the high levels of over-utilization of hospital care partly driven by inaccessibility to primary care services, digital consultations could lead to improved access to certain services at lower unit costs [10].
The number of digital consultations that are currently taking place globally is unknown. In the USA, the market for telehealth reported sales of some US$9.6 billion in 2015 and is expected to grow by 32% over the next few years [11]. The Veteran Affairs’ telehealth program provided some 1.7 million telehealth episodes of care in 2013, a number expected to increase over the coming years [12]. In the UK, the government expects the number of people reached by telehealth services to exceed 3 million by 2020 [13]. In Sweden, estimates from such providers suggest that the number of digital consultations is around 60,000 to 80,000 per year (in a population of some 10 million people), mostly for primary care type of services. Also, the number of providers of digital health care services is increasing, and examples can be found in most European countries, North America, and some other regions [14, 15].
The digital health care model will most likely increase both in scale and scope over the coming years. More people will gain access to a digital health care provider, and more types of services, including specialized care, will be offered by this model of care. To make sound investments in health care, evidence is needed on the effects of new technologies, including their economic costs. The main purpose of this study is to contribute to the expanding body of evidence around the impacts of digital innovations in health care. In particular, it aims to evaluate the cost of a digital care model compared with that of the traditional (in-office) way of providing primary care in Sweden. The perspective is that of the whole society, including the costs to both providers and users of the services. Based on the analysis, the study then simulates the impacts of incrementally scaling up the digital model by different rates of substitution.
Primary Health Care in Sweden
Health care in Sweden is the responsibility of regional governments (counties). There are 21 regions in Sweden that fund inpatient and outpatient care by means of general taxes, state grants, and user fees, the rates and levels of which vary across the regions [16]. The most common way of obtaining primary care is to make an office visit to a primary care clinic (in Swedish Vårdcentral). There are around 1150 such clinics throughout the country. On average, two-thirds are run by the regional health authorities directly and one-third are privately owned practices that contract with the regional authority. The primary care clinics differ in many ways from those in some other countries where such types of clinics are owned and run by single or multiple general practitioners (GPs). Most primary care clinics in Sweden are staffed by several different types of providers, including GPs (between four and six per clinic), nurses, and physiotherapists.
About 14.5 million primary care visits take place annually in Sweden, equivalent to 1.4 per person [17]. The total spending on primary care was around SEK28 billion (US$9 billion) in 2015 [14]. Over past years, per capita spending on primary care has been increasing in constant terms, suggesting an underlying issue with cost pressure [16].
In addition, there is broad public and political concern over inadequate access to medical services, including primary care. Over the past decade or so, a number of reviews have pointed at issues with access to services, both with respect to unequal access across socioeconomic groups and across geographic areas [16, 18, 19]. Recent reforms have aimed at improving the general public’s access to health care by, among other things, introducing enhanced patient choice and free provider establishment of primary care practices [20].
One underlying problem facing the Swedish primary care system, and one that it shares with most if not all other countries, is a shortage of human resources for health. The national government has set a target of around 1500 inhabitants per GP. However, the current number is over 2000, making it difficult for policy makers to reach set goals of access to services [13]. Determining the extent to which digital models of care can contribute to solving the challenges of access to health care services in Sweden and elsewhere will require further studies of their impacts, including those on costs.