Response to interpellation 2022/23:185 on obesity as a market for online doctors
Translated from Swedish by AI; the translation may contain errors. The Swedish text is the original.
Summary AI, written in advance
KD considers that patient safety is important and that digital healthcare providers are subject to the same legislation as physical care 1 2. KD emphasizes that private operations without regional agreements fall outside the pharmaceutical benefit and that the investigation should find principles to include digital healthcare providers in the system based on the principle of need 2 3. KD wants tax money to go to those who are ill and that it should not be assumed that everyone wants to lose weight 3. KD considers that the principle of need must be included in every system so that triage occurs and the patient receives the correct care intervention 4. KD wants patients to be able to choose between physical and digital care 4. V argues that the unregulated market for online doctors creates a profitable business that conflicts with the Health and Medical Services Act 5. V wants to regulate online doctors and abolish the right of free establishment 6.
Written by AI in advance and may contain errors. The numbers lead to the speech a statement builds on; check against the text below.
Statsrådet Acko Ankarberg Johansson (KD)
Madam Speaker! Karin Rågsjö has asked me what measures I and the government will take to prevent patients from suffering harm due to the activities of online doctors. Karin Rågsjö has also asked me what measures I and the government will take so that the activities of online doctors do not conflict with HSL, the Health and Medical Services Act. Finally, Karin Rågsjö has asked me how I and the government will follow up on the various activities of online doctors that target, for example, mental illness, high blood pressure, and obesity.
First and foremost, I want to emphasize that patient safety within healthcare is an important issue for the government. Regardless of whether it concerns physical or digital care, one should be able to feel secure in receiving help when seeking help in healthcare. One should be able to trust that the healthcare provider one chooses to seek help from has adequate education and follows the legislation and the guidelines that exist in the area.
The Health and Social Care Inspectorate, Ivo, exercises supervision over healthcare and its personnel. This also applies to digital activities. If Ivo becomes aware that healthcare personnel are not fulfilling their obligations according to the applicable law for healthcare activities, the authority shall take measures to ensure that the obligations are fulfilled. Ivo also has the authority to report licensed healthcare personnel to the Health and Social Care Responsibility Board for consideration of intervention measures, for example, revocation of license or limitation of prescribing rights.
Finally, I would like to thank the member for her long-standing commitment to healthcare issues and, not least, for strengthening patient safety in health and medical care. I thus look forward to a continued good dialogue.
Karin Rågsjö (V)
Madam Speaker! Thank you for the answer, Minister!
We experience that everywhere within healthcare, a web-based medical company appears where it is possible to earn a lot of money. This happens without regard for what the healthcare needs actually look like. It is because we, through the freedom of establishment, have a completely unregulated market for healthcare companies in Sweden.
I experience that it is probably the worst control among the digital actors, who are allowed to earn money in a way that we consider to be in conflict with the Health and Medical Services Act. It should be the needs that guide, not just that one constantly seeks care.
Madam Speaker! New appetite-suppressing drugs have entered the market that make it easier to lose weight. It must be said that this is good. It concerns semaglutide, which is also found in diabetes medications and in Ozempic, Saxenda, and Mysimba. These medicines and treatments suppress hunger and increase the feeling of satiety.
The demand for Ozempic, which is only approved for type 2 diabetes, is so great that there has been a shortage at the pharmacies since last autumn, according to Dagens Nyheter. It has affected diabetes patients.
One can wonder if it will come like a letter in the mail that new digital overweight clinics see their chance, we believe, to earn extra money and open for business when it comes to exactly obesity and overweight. The same development can be seen in other medical areas, for example when it comes to high blood pressure and mild mental illness. Because we have a completely unregulated market, the online doctor companies appear. They do not have contact with general practitioners but operate entirely on their own.
As many as 1 million Swedes suffer from obesity. It is a major public health problem and has, in our opinion, become a profitable business for a number of healthcare companies. There are healthcare providers such as Yazen and Medfacilis, which offer contact with doctors via app or web and monthly subscriptions that cover both the prescription of medicines and personal diet and exercise programs. It can sound very good.
The patient pays for the medicines themselves. Actually, the treatments, the medicines, are intended for people who have obesity – they are not just slightly overweight, as one can feel sometimes – or have diabetes linked to the overweight. This has also been shown to reach a fairly large number of people. They have, for example, gone on Facebook and found groups on the theme Ozempic and in that way been driven to a healthcare provider. It is ultimately a business idea that does not feel okay, we believe. It stands a bit apart when it comes to the rest of the healthcare. It is more of a business for a number of people.
I think this is a part of the health and medical care where it is a bit of a Wild West and needs to be regulated. I wonder again what measures the minister wants to take to prevent patients from suffering because of the activities of online doctors. This concerns, for example, that medicine intended for those who have diabetes instead goes to some who consider themselves a bit overweight. And what is to be done otherwise regarding online doctors who work with blood pressure and open a digital clinic for that but do not have contact with, for example, other healthcare?
Statsrådet Acko Ankarberg Johansson (KD)
Madam Speaker! Thank you, Member, for a very interesting question! It concerns many aspects of health and medical care.
It is the same responsibility regardless of whether one is a digital or physical healthcare provider. There is no difference in the legislation. The responsibility is the same. All providers are subject to the Patient Act, the Patient Safety Act, and the Health and Medical Services Act. There is no difference.
What differs, however, is that none of the examples the member gives, as far as I know, have agreements with any region. It is entirely private activity. The medicines that are prescribed are also not part of the pharmaceutical benefit and have therefore not been assessed by TLV. It is not a political decision. It is an authority that assesses which medicines should be subsidized collectively. These lie completely outside.
It is indeed a private activity on the side. But it is fully and completely subject to the laws that govern healthcare. Therefore, Ivo, our supervisory authority, is responsible for following up that it is done in the correct way. One such thing is that one must prescribe for the correct indication. In some situations, it can be correct to prescribe in another way. It is sometimes called off-label. We can, for example, see it at certain times when it concerns those with MS, where a medication that is often used is off-label. Other times, it can be completely wrong.
Furthermore, it leads to a shortage situation for the groups that need the medicine. This has been relevant, not least in this case. Patients who need a medicine are left without because patients who are not sick and do not need the medicine receive it instead. It is an example where our supervisory authorities must be active and act in the manner they find appropriate based on their instructions and the regulatory letter they have received.
If any of these healthcare providers were to have an agreement with a region – some of them might have it, even in certain parts – it is the region's responsibility to follow up on this.
The government is not standing still. It is, in fact, a completely different situation today, when we as patients can take part in digital services. It is very good that we can have both physical and digital visits. I believe the member agrees with that. During the pandemic, that development gained significant momentum. Before that, there were only a few actors involved, both publicly run and private. Now it has truly changed. Today, I believe that almost all regions offer the possibility of different variants of digital meetings that suit patients in quite many situations.
What we need to achieve is that this becomes a part of the health and medical care system. So, I understand the question from the member. The initiatives are good, but they must be a part of our healthcare system so that they are based on needs and do not run alongside them. An investigation has therefore been commissioned as a result of a motion from the Riksdag, which I believe both the member and the undersigned stood behind at the time. Björn Eriksson is leading this. Principles must be found for how digital healthcare providers shall be included in the system, and it must be based on the principle of need. The investigation will submit its proposal later this summer. Then we will have to return to how we handle it.
I believe there is a desire among all actors for some order in the system. This also applies to the digital healthcare providers, if they exist in the system—it is not the examples the member raised—they almost always end up in the out-of-county placement today. It is based only on the number of visits and not on making holistic assessments and taking responsibility for patients. It is a system that I perceive neither party thinks is favorable, but rather that they want to change.
I hope that the ongoing investigation can also contribute to a better stance and to us obtaining a national system that can support the development in the right way and based on the laws we have in the area.
Karin Rågsjö (V)
Madam Speaker and Minister! That sounds commendable. I hope that the investigation becomes something that we can take part in.
Furthermore, these treatments, which have been developed for people suffering from obesity and diabetes, are now being sold as a kind of miracle medicine through various digital medical companies. When one starts advertising such things on Facebook, we think it has gone a bit too far.
The problem also becomes that a number of the independent network doctor companies that are outside the shell have no contact whatsoever with or links to family doctors. There is no such thing.
It has also been shown in reviews made by Dagens Nyheter - which is an extraordinary newspaper, and now I have done a bit of advertising for it - that it is quite easy to receive this treatment, even if one has an overweight of five kilos and then hardly needs it. This is how we cannot have it, Vänsterpartiet believes. Proper investigations, follow-ups and physical meetings are required if one has a severe overweight or an overweight. It is always good to meet a doctor.
The marketing of online medical companies is very active. One can see their billboards in the subway here in Stockholm. The advertising has made this a very profitable business. One can really wonder if it has also led to more equal healthcare, since online doctors, according to surveys from Vårdanalys, are most frequently used by people who live in the inner city and are quite healthy but want quick access to care.
Everyone loves that the digital conditions make it easy to get in touch and speak with doctors, but here it is also about the regions having to take command of the digitalization. That has not quite happened. One should, for example, develop 1177 and offer online bookings. Vänsterpartiet is quite worried that the online doctors continue to make a killing in a number of areas. It requires neither calls nor anything else; instead, a patient can call, get medicine prescribed, and pay for it outside the system they should actually be inside.
Vänsterpartiet wants to regulate the online doctors - that is quite well known - and abolish the free right of establishment but at the same time maintain the patients' freedom of choice. We think that these are very important issues, and they are also issues that are becoming more and more relevant. It is about how one can be able to safeguard the taxes paid to health and medical care and which patients who should receive a share of them - preferably those who have the greatest needs.
The Minister has stated that an investigation will be launched, but I wonder if it will in any way receive directives that can lead to measures so that the online doctors can truly become a part of the healthcare system.
Statsrådet Acko Ankarberg Johansson (KD)
Madam Speaker! I cannot comment on an investigation that is not yet finished, but there is a need to get the system in order and for different actors to be given the opportunity to participate. But all compensations and fees must be based on the principle of need, and they are not today. One must say that all regions are complicit in that. A compensation model has been chosen without requirements for needs assessment, but it is my opinion that it needs to be included because that is how our laws are designed.
Let me take a step back. What the member highlighted in his interpellation concerns entirely private activity where the patients finance everything themselves. There is an additional problem, I think, based on the question concerning the belief that one always has to lose weight. That is not always the case.
There is an ideal that says one must seek all the help one can to lose weight. I think that question is also present here. For me, it is obvious that the one who seeks help for obesity - which is usually the medical term when it concerns overweight in some form or obesity - and wants help, absolutely should get it. At certain indications, weight can be an important factor that one needs help with, but I also meet many people with high weight who get that as an answer when they have sought help for something else. It therefore becomes a discriminatory attitude if one is always assumed to want to lose weight.
In this case, I believe that one needs to work on the realization that everyone is different. The important thing is to have good health. Weight is not always the factor that determines whether health is good or not, but it can do so. For certain diseases, it is an important factor. Healthcare should always provide a good reception. It must be ensured that the person seeking help for these types of issues receives the best reception and help in the best way. Unfortunately, there are many stories that it does not work so well today.
When it comes to the point the member highlighted now regarding the view that one should lose weight, we must find an arrangement where common tax money is not spent on those who are not ill. Common tax money should go towards screening when it is known to be effective, that is, when there is a cure and when treatment can be offered. The money should go towards preventive measures that are evidence-based and, of course, to a health and medical care that provides help when one is unwell.
If we direct too many measures and resources towards those who are healthy, we will use tax money incorrectly. Therefore, it is important with systems that are based on the principle of need. I hope that the upcoming investigation helps us find a better order. I actually believe that most actors within the health and medical care systems who are digital want a better order where one sees that one is part of a system.
In the acute issue that the member raised, it is the supervisory authorities that need to do their part in the way they deem correct, and when it comes to what the government does that is long-term for the system, we hope that the investigation can assist with parts. Otherwise, we will have to return in another way to find a better order forward. Both digital and physical healthcare providers are needed, but there must be order and clarity in the system.
Karin Rågsjö (V)
Madam Speaker! It would be very good to have order and need-based management. I believe that this has been abandoned to an all too great extent, and it affects those who are in the greatest need of care. They somehow end up last in the queue.
It is very good with technical solutions, apps and all such things that should exist. It is a given today, I believe. It would be very good if, from the regions' side, one strengthened for example 1177 and worked it in a good way.
The Stockholm region is now removing its inland compensation. I think that is good. Perhaps more regions should do so. The compensation is 300 kronor per visit and has been given to digital health centers in the region that receive those who call them but are registered somewhere else. It is a way to counter this. Several evaluations of online doctors show that they cost quite a lot for the regions and that they are often used by people who live in inner cities and are not very sick, but on the contrary just want quick help. In that case, it is not the needs that drive it, but rather the conditions for getting hold of a doctor quickly—for ailments that may be minimal. It would be very good to move away from that.
Statsrådet Acko Ankarberg Johansson (KD)
Madam Speaker! It is important issues that are raised by Member Karin Rågsjö, in order to move away from the idea that it is always important to lose weight. That is not the case. It is an important message to the public that what is important is that one has good health and receives help when one is ill. That is where the needs-based management must come in. People should not live according to ideals that are incorrect and provide incorrect images.
There is work to be done in healthcare to ensure that the management systems are based on the principle of need. This has been neglected. The principle has not been included in the agreements and regulations despite being included in HSL, the Health and Care Act, and appearing in several places. My view is that it must be included in every system so that some form of triage – a needs assessment – is performed and the patient receives the correct care intervention. This could, for example, be meeting a doctor, a physiotherapist, which is common in the case of osteoarthritis, or an occupational therapist.
One should also have the opportunity to choose between physical and digital care depending on one's situation. First, a diagnosis is often needed, and in that case, the physical meeting is usually important when it comes to many diseases and conditions. Other things can be managed digitally. We must find systems that hang together and replace them in the right way. The needs assessment is central.
I hope to return to the Riksdag in the future with proposals that strengthen this part. I am grateful that the member raised the issue and that we in that way contribute to a good discussion.
Source: The Swedish Parliament. The speeches come from the open data of the Riksdag, translated into English by AI, which may contain errors.