On value of solidarity in healthcare

Photo: Liis Treimann

Health Insurance Fund (HIF) chief executive Tanel Ross ponders the topic raised by healthcare expert Ain Aaviksoo: is Estonian version of financing healthcare obsolete and in need of greater patient participation and responsibility? Is it right to redistribute healthy people’s money to those that are sick?  

How do you counter the criticism of financing of the healthcare system being outdated and based on the principle of ever increasing service units available, instead of measuring outcome of treatment?

It seems to me that Mr Aaviksoo is not putting down the entire system; rather, he is suggesting that we ought not to present a bill for each service, rather measuring treatments and its effectiveness. It’s the eternal question in healthcare: how to define healthcare services from financer point of view. Broadly speaking, two approaches exist which we are also using in Estonia.

On initial level i.e. family doctor service financing entail paying each family doctor a certain sum per year, as corresponding to the number of people in her list; in return, the family doctor promises to provide needed quality services. In specialised medical care we pay for each treatment case – not necessarily for each service, as a treatment case will contain several services. Also, in in-patient treatment we combine service-based payment with diagnose-based financing. Our payment system is nothing unique; in principle, this is the essence of it everywhere.

Perhaps Mr Aaviksoo thinks we should expand the family doctor based financing to specialised medical care?

He is saying we ought to apply a broader definition on cases of treatment – I go to family doctor, then to an out-patient reception, then I’m directed to in-patient treatment, and thereafter the rehabilitation; we would measure the entire process and pay for it some definite single amount.

The current system has been dubbed micromanagement.

I do not agree to the term. With a large part of initial level receptions, we do not «micromanage» anything. With out-patient specialised medical care we do indeed pay for one visit and the resulting investigations as deemed necessary by the attending physician.

It may be presumed that such an approach will support a situation where the provider of services may generate more visits. I cannot agree with the claim that Health Insurance Fund and doctors are not interested in people visiting doctors. This is just not true – not by form, nor by content. The opposite may be true: on the out-patient side more investigations may be performed than is necessary, as HIF pays it all.

What would HIF like to change, with the system?

We have indeed been thinking to introduce results in payments i.e. to pay when a person is really made whole, figuratively speaking. 

Ensuring health-behaviour of the patient is clearly stated in HIF development plan, both the issues and ways to go about it. But how to take that direction… honestly, this is very complicated. Who then do we remunerate? Shall we give all the money to the family doctor who, as if, is outsourcing services from various players to treat her patient? What do we do when it is concluded that the treatment lacked quality?

Mr Aaviksoo makes quite a lot of sense, but how to apply it is a complicated matter. To begin with, information is needed to measure quality of treatment. While we currently lack an effective state system to compare quality of treatment between hospitals, how then can we talk about making payments on an altogether different basis?

Perhaps changing the system is held up by e-services?

E-services are important indeed. The main prerequisite for e-health is to have easily accessible information on what medicines a person has used, which diagnoses he has had, how he has been treated. When thinking on rather paying for treatment results and monitoring the whole process of it, we should have the information what has been done with the patient. Do we have all these prerequisites in Estonia, at the moment? No.

Looks like a main idea of Mr Aaviksoo’s is to increase individual responsibility in health care, as well as own participation by patients. What do you think about that?  

When asking if I and you should take responsibility for our health, the answer is naturally yes. I think promotion of health and prevention of sicknesses is very important in Estonia. First and foremost, it is important for people to know how to live so as to have greater probability of longer and healthier living.

On the other hand, they say that what I do in live greatly depends on what I’m willing to pay for it. This is a clearly political decision, to which products and how much excise we impose. The obvious examples are tobacco and alcohol excise; but, to my knowledge, there is no evidence in the world on effectiveness of tax policy measures.

Could insurance payments be linked to how a person lives, what his health-behaviour is like?

Globally, a sure correlation has not been detected between insurance premium size and healthy lifestyle, especially with universal healthcare insurance. It has been investigated that while motivating people to quit smoking or have poorer people to attend screen measurements, this works for a while but may not produce long-term change. I still think that in Estonia it makes sense to invest in prevention, like screen measurements for cancer.

The health expert says it is not possible to have «traditional redistribution of health insurance from the healthy to the sick, or from the young to the old», that it should rather be adjusted to personal risks.

I am sure that in this small society of ours, solidarity isn’t just a moral notion in health insurance; it has also had a vital positive effect on national health. In other words – a more equal access and smaller differences in health indicators of societal segments have a positive impact on national health as a whole.

The United States is a typical example of the entire healthcare system built on private healthcare alone. If a person there has a good insurance, he is sure to get good medical care; but there is a large part of the population who get no medical care. A glance at USA’s average health indicators shows us theirs are worse than in Europe with its solidary system.

Perhaps it would be better to collect the money into healthcare funds?

There is the version of imposing the so-called pension pillar system where a person saves and lays money aside in the hopes of having enough and getting extra help to what the state provides. Then, the society will need to accept that the rich do have better access to healthcare.

There are countries where health accounts are used, like Singapore. There, repeatedly the need for additional funds has arisen – to cover actual costs that occur.

I think that any sudden increase of own participation will mean that those that are better off will get more and those that are worse off will get even less. Inequality will increase and, overall, national health deteriorates.

How effective, as compared to other countries, is our current financing model?

Of Estonian gross national product, relatively little goes to finance healthcare – over five percent. In Europe, the average is nine, In USA 17 percent.

While looking percent-wise on the amount everyone pays into overall treatment, it is quite the EU average in Estonia. Here, the situation is that a person pays little for visiting doctors; more money is spent on medicines and dental care.

Will there be dental care compensations for adults?

We are analysing dental care as a whole, not just the renewal of current financial compensations. For instance: free dental prevention and treatment is provided for children, but our options aren’t being fully used. We have also ordered an assessment by international experience. We will present out proposition to the council in August.

Diagnose-based financing

Is a case-based financing system used in Estonia where patients with similar clinical state and resource-costs come under one group. This is based on the assumption that, to treat patients with similar diagnoses, a certain amount of services is needed – the average price of which is a fixed amount. If a person goes for in-patient treatment at a hospital, Health Insurance Fund pays 30 percent of costs of services and 70 percent of the agreed cost of treatment of patients with the diagnosis.