Health insurance fund will not back down

Photo: Erik Prozes

Even if local people will succeed in changing the minds of the supervisory boards of the Valga and Põlva hospitals and their delivery departments will not be closed this year, there is hardly cause for celebration. Member of the board of the Estonian Health Insurance Fund Pille Banhard says that the fund will not back down, and the small hospitals will lose funding necessary to support delivery departments.

Closing the delivery departments at the Valga and Põlva hospitals has been talked about for decades. What was that last drop? Why has the fund proposed to close them now?

Põlva Hospital has been telling us they cannot make ends meet for years, that the fund’s contracts volume is so small they cannot maintain their delivery department or ensure its preparedness around the clock. When we saw the projected number of births at the hospital fall below 200 this year, we launched negotiations.

Postimees wrote years ago how Põlva Hospital’s delivery department is only alive thanks to patients from Russia. All of it was known, yet you made the proposal only now.

Processes take time, and you have to help some decisions along sometimes.

Why did you decided to close the delivery ward of the Põlva Hospital and not the South Estonia Hospital (in Võru – ed.)? Põlva Hospital’s department head Sirje Kõiv recently told Postimees in an interview that shortage of medics is much worse in Võru, and that women are sent to Põlva in ambulances.

That is an emotional statement. When we mapped the three hospitals (Valga, Põlva, and South Estonia -ed.), the latter had the best healthcare figures. The difference between Võru and Põlva is not great, but there were so few births in Valga…

How surprised were you at the level of opposition? You were forced to take a step back, and the delivery ward at the Põlva Hospital will be closed in October, not this summer.

We were surprised. We were not naive enough to think there would not be resistance. Heads of hospitals understood the decisions, but the reaction of the community… Our communication should probably have been different. We have done our best to calm them down.

How did you manage to make the decision behind the back of Minister of Healthcare and Labor Jevgeni Ossinovski?

We did not decide behind the minister’s back.

So, it was a purely political move for him to deny knowledge?

We inform our supervisory board, including its chairman, of such changes. When we were in talks [with hospitals] in January and February, the supervisory board was briefed, also on proposals we made to hospitals.

The minister did not find the decision premature?

Not in the supervisory board.

Doesn’t it make you feel powerless? The fund tries to make the most effective use of treatment funding only to have the politician heading the supervisory board come out and say it’s all wrong. It was the same situation a few years ago when the fund wanted to reorganize specialist appointments in small hospitals which prompted Ossinovski to say that the fund is going beyond its commission…

I think that people sometimes feel powerless everywhere. Sometimes good plans get postponed. When you want the best, make proposals based on analyses and then experience a setback – whether a political or financial one – you still have to think about how to solve the problem.

What will happen should the supervisory board of the Valga Hospital decide on Tuesday that they will not stand for the closing of the delivery ward? Will you starve them out?

We would not like to have to starve them out so to speak. The health insurance fund has very clear principles and rules based on which contracts are signed with hospitals. The Valga Hospital will not get more money than we see a need for in births projections.

We have a pilot project in Hiiumaa where we have a hospital contract based on different grounds. The hospital there gets a lump sum from the fund and uses it as it best sees fit to ensure everyone has access to proper healthcare. Hiiumaa will have to show whether such a system could work. However, we do not want a situation where we just start giving hospitals more money.

Head of the Põlva Hospital Koit Jostov would like to get €200,000 as a so-called standby provision as it would allow him to retain his delivery department. Will he get it?

No. Our information suggests they have decided to close the department.

What if their parent hospital, the University of Tartu Clinic, gives up so to speak and changes its decision?

Our financing principles will give Põlva Hospital funding for as many births as projections show. We know Jostov wants his standby provision, but he is not getting it just like that.

How feasible would it be to finance small hospitals, like those in Põlva and Valga, following the Hiiumaa model?

Hiiumaa is a test project to see how and whether such a system could work. We could talk about which mainland hospitals could adopt the model in a few years’ time. I’m not ruling out it could be used elsewhere in the future. However, that decision would be based on thoroughly analyzed methodology; we absolutely will not simply give hospitals more money.

Healthcare was financed based on that general scheme in Latvia, where a lump sum was allocated from the state budget. And usually it had run out by November. Latvian colleagues told us that it was unwise to get into a car accident in October as you never knew whether they’d have the money to patch you up. That is why they wanted to change their system.

Healthcare is a house of cards that is subject to chain reactions: if a hospital no longer delivers babies, its anesthesiologist will have less work. Which medics will find themselves light on workload after the delivery wards close in Põlva and Valga?

Heads of hospitals did not say any specialty would suffer as a result. We did not see that happening, and they did not currently point to it either.

How profitable is a delivery to a hospital?

The average price of a birth in the South Estonia region is €1,100 that should be enough to cover premises and staff expenses. This average does not reflect risk pregnancies but only women who are healthy. One such birth every day would suffice to keep a ward open.

Will the health insurance fund start paying for people from remote villages coming to stay closer to the hospital a few days before birth after the delivery wards are closed? Because it is difficult to drive a car while having contractions and your husband is working in Finland?

We will give the matter some thought. What we have right now is a catch-22-type situation of whether to first have a patient hotel and then add the service to our price list or to fund the service first and then set about organizing patient housing. We will discuss it.

We will not say it is not our problem how the University of Tartu Clinic or the South Estonia Hospital handle patients about to give birth. The same goes for transport compensation.

All of it should have been considered before deciding to close the departments: the reaction would have been a lot milder.

All these processes take a long time, and it is something the clinic has considered, but in the end, it all boils down to communication.

Head of private hospital Fertilitas Ivo Saarma said five years ago that Estonia could get by with just two maternity hospitals as we have so few young women. How likely is that scenario?

It sounds very pessimistic. We need to look everywhere in Estonia in terms of what to do so that life would not concentrate only around Tallinn and Tartu, leaving other regions empty. I hope it will not come to that.