Health insurance fund has made hurried decisions

Maris Jesse.

PHOTO: Sander Ilvest

Even though Estonia still has more hospitals than recommended by Swedish experts in 2000, Deputy Secretary General of the Ministry of Social Affairs Maris Jesse finds the Estonian Health Insurance Fund has made several hurried decisions in trying to limit specialist care in county hospitals.

How well could the Swedes who planned changes to the Estonian hospitals network in 2000 foresee what would happen in Estonian medicine?

I went over the Swedes’ strategic plan and didn’t notice any blunders. However, it was clear in 2000 that birth rate forecasts were too optimistic. We almost reached the projected 15,000 annual births for a time, but it has come back down by today.

Their other recommendations have been entirely businesslike.

Why was the Swedes’ plan criticized so fiercely back then?

I wouldn’t go as far as calling it that, but it is understandable people were afraid of losing access to medical care if the forecast prescribed closing hospitals.

That is exactly the problem we have with obstetrical care in Valga and Põlva. The proposal to close the hospitals’ delivery wards was made without thinking it through, putting it on paper, and without discussing with locals how to ensure monitoring of pregnancy, delivery, transport to and from hospital, overnight stays etc. Had these matters been discussed with doctors and local people beforehand, we would have seen much less fear.

The Swedes’ development plan recommended Estonia to have 13 hospitals, while we currently have 20.

There is no sense in debating the number of hospitals. The important thing is to have medical assistance no more than an hour’s drive away, but county hospitals cannot be compared one for one. We need to look at the hospital’s service area and sustainability of services. It is important for people to be able to get emergency assistance in a given amount of time, without having to drive for several hours. However, the hospital in Valga doesn’t necessarily need to offer the same services as the one in Rakvere.

Was the health insurance fund’s plan from two years ago to allow every county hospital to only maintain eight primary disciplines wrong?

Yes.

At the same time, the Swedes say Estonia should determine which specialty doctors can work in county hospitals.

Those recommendations are from a time when Estonia had enough doctors and hospitals were rather thinking about creating new services – an arms race. We have a different situation today, 20 years later.

We are not talking about containing the arms race but rather making sure people feel safe everywhere in Estonia. The hospital cuts are not due to budgetary reasons; the reason is looming shortage of staff. We need to find ways of ensuring medical services in smaller places.

The fund believes patients will turn to county hospitals even more seldom in the future – that family physicians will send them to major hospitals in Tallinn or Tartu right away.

There are diagnoses that take a person straight to a major hospital today. Cases where the ambulance is forced to take the patient to a major hospital are even more numerous. What we are left with are conditions best treated locally. That will in turn depend on the local hospital’s capacity and level of preparedness.

That is why we should give up the mindset of someone somewhere deciding what is okay. We should look at how it would be most sensible.

Who will decide which specialties county hospitals will get to keep?

County hospitals tend to lose specialties because there are not enough local doctors. It’s force majeure.

Young doctors do not go to work in county hospitals because there is not enough work there. It is not a decision made by the ministry or the health insurance fund.

Shortage of medical staff is our problem, and we are working on motivating people to work in smaller places.

However, if a small hospital has an experienced doctor who is not planning to retire yet, I see no reason for anyone to decide their service will not be offered at the hospital starting next year – if the locals need it and the doctor is available.

Will the principle of treatment being at most 70 kilometers or an hour’s drive away be retained?

We have not discussed changing it.

One thing that needs to be solved is transport expenses. When the Medical Insurance Act was being drafted in 2001, transport compensation was included in the bill but taken out by the Riigikogu. We will come back to it, as a person living in Central Estonia must incur costs citizens of Tallinn or Tartu do not have when seeing a doctor at a major hospital.

If population decrease means that it is impossible for a specialist doctor to work in some areas, how many more ambulance brigades would Estonia need?

They do not have to be ambulance brigades. However, organization of suitable medical transport or compensation for traveling expenses must be considered. An ambulance is needed when there is medical assessment to be made or when a person’s medical condition needs to be monitored by a qualified person during transport. Without an acute medical problem that requires the presence of a medical professional, ambulance rides are not justified.

Heads of the Valga and Põlva hospitals find that small hospitals should be paid a so-called standby fee.

We have not received corresponding applications from either hospital. We will discuss it should that day come.

However, it’s clear it is no way to construct a sustainable healthcare system when a Tartu doctor spends their weekends working in another hospital. That is only suitable in emergencies. Doctors also need time to recuperate and their families want to spend time with them.

We could save money by renovating small hospitals. Viljandi Hospital will get a new building that people can access more easily and that has half the floor space. The hospital estimates that they currently don’t need 40 percent of their premises which they still have to heat.

Old hospitals have already been fixed up using European structure funds.

Decisions are made in their own time, and investments into hospitals tend to not only be rational but also follow political considerations. You cannot remake them later. Renovation of some county hospitals, like what is being done in Viljandi, should have been considered in the mid-2000s.

The social ministry has said that changes to hospitals’ work allocation will continue in 2030. What does that mean?

The overhaul of the network of hospitals began last year with the help of foreign consultants, but there was no sense in taking it forward until we had certainty in terms of healthcare funding. Now, we will move on to specialist medical care and the hospitals network.

Aren’t you a little behind? The National Audit Office concluded it was hopelessly late to address the problem already back in 2010.

Healthcare financing decisions were late. I would have hoped to see the decision 10 years ago. However, you cannot remake decisions already made, you can only make better ones in the future.

Head of the Tallinn Children’s Hospital Katrin Luts said last week that she signed the plan to merge three major hospitals to spark a debate of what the hospitals network should be like. It has not been sparked.

That sentence first and foremost reflects frustration with outstanding healthcare funding decisions. By 2016, medics had lost faith that necessary funding could be made available. I dare say based on experience that had the state approached hospitals to talk about cooperation and changes to the network when treatment availability was falling every year, it would not have been received well.

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