How to move further from treatment based financing?

“Today's planning of health services in treatment cases will help to manage specialized healthcare costs, at the same time the strategic purchase of health insurance must develop more in order to better value the comprehensive treatment process and its results,” says  the Chairman of the Management Board of the Estonian Health Insurance Fund, Tanel Ross.

The mission of the Estonian Health Insurance Fund is to ensure the availability of healthcare, discount medicinal products, other benefits, and the sustainability of the health insurance system. This means that every day difficult choices must be made - the demand for healthcare services exceeds the possibilities to pay for it both in Estonia, elsewhere in Europe, and also in North America, Canada, and Australia.

Broadly speaking, two models are in use today in Estonia in terms of how healthcare services necessary for people are purchased - family physicians are remunerated on the capitation fee basis (a family physician receives a flat fee for each person included on the family physician’s list) and specialized medical care is purchased by treatment cases. This means that the Health Insurance Fund will buy from hospitals a specified number of treatment cases by specialty in the agreed volumes. Both models are widely used internationally.

However, there is no perfect model, and with the changing needs of society, the strategic purchase of health insurance has to evolve as well. Limited financial resources, the ever-increasing treatment options and the number of older patients and patients with chronic diseases forces us to consider how better to organize a coordinated movement of the patient in the healthcare system. It is important for a person to go to the right doctor at the right time, and that the diagnosis and treatment of diseases would be carried out in cooperation with all parties in order to achieve the best results.  Results would be even better if a disease can be prevented in a timely fashion with effective and evidence-based methods.  Prevention methods require significant attention.

On the other hand, it should be emphasized that, although the current “piecemeal” purchase of specialized medical care has received criticism because such a model is more focused on one case rather than the cross-treatment type comprehensive approach to the treatment process of the patient, the treatment case based purchase is also our strength. The Estonian healthcare system is considered to be very effective. A prerequisite of a well-functioning and efficient system is that we are able to track and predict trends in the provision of medical services and to use that knowledge when assessing the need for services and in planning the commission of the Health Insurance Fund. The detailed list of services and the purchase of specialized medical services based on treatment cases allows us to take account for the uniqueness of each medical specialty and to make binding agreements with healthcare institutions in terms of the volumes of services provided to patients. The exact analysis and planning mechanism that has been in use for a long time ensures transparency and creates favorable conditions for further development of the system so as to provide more support and cooperation among the parties of the healthcare system, and to focus more high-quality treatment results in remuneration for the services.

Many significant steps have already been taken for moving toward this goal. International analyses show that the healthcare systems that are developed around strong primary medical care methods are more effective. In such countries, the results are better in the general health outcomes of the population, moreover, in these countries patients give higher evaluations to the healthcare system, and to the availability of services. Therefore, increasing the opportunities for primary care and supporting the ever-increasing role of general practice has been an important goal.

The development of the primary level model will enable us in the future to offer both the insured person and the family physician a greater choice of services, faster access to services, and overall better-coordinated care. Important roles are played by the development of a quality system, improving the effectiveness of prevention, as well as the development of case management.

Organization of more flexible purchasing of health services makes it possible to develop a system that primarily buys treatment services according to an outcome based principle. This means that the patient’s treatment is integral where the results are measured on the basis of the patient's health outcomes, not on the basis of the provided services. Moving on to an outcome-based purchase, we will be able to regard the patient's entire treatment journey as one unit. For example, treatment of a patient with infarction includes both timely arrival at the hospital, treatment of the acute disease, as well as rehabilitation and future monitoring of the health of the heart in the family physician’s system.

In the long term, on the integration of primary care and specialized medical care, we will be able to provide patients, especially those with chronic diseases, with more holistic treatments. Integration gives the family physician an overview of all the possibilities of the healthcare system and helps their patients to choose a specific service in a timelier manner. Cooperation and integration will also improve the necessary services in specialized medical care, rehabilitation, and nursing care. The family physician's role becomes a real treatment coordinator, as the family physician is the person best familiar with the person’s health, and can also provide effective prevention methods. He or she knows the diseases that have already been in the family, is able to discover and spot the symptoms, and then provide advice.

In cooperation with the World Bank, we have since 2013 been analyzing the Estonian healthcare system and health insurance, and have developed activities in order to achieve the specified goals. Today, we have reached the second phase of the strategic purchasing development project. In cooperation with Estonian experts, and with international support, we are further developing models for the purchase of services and analyzing the planning of waiting times, so that the waiting times would be more dependent on the health situation than other factors, and we are carrying out the so-called risk patient model pilot project (for patients with chronic illnesses who need counseling and monitoring). So we are moving forward together toward more integrated healthcare, supporting both the doctors’ and the patient's roles.

However, it should be emphasized that moving towards a more centralized system of treatment outcomes, will require substantial preparations from all the parties in the system. The most important prerequisite is, of course, the evidence-based comprehensive treatment processes, which are very substantially supported by adherence to modern clinical guidelines and algorithms. Very important is the role of technical preparations, such as the uniform implementation of the electronic documentation of the treatment processes aligned with the relevant international standards. Also, measuring of treatment outcomes and quality indicators, and publishing the results thereof, along with continuous monitoring of the patient's comprehensive medical expenses and implementation of clear and uniform principles of keeping waiting lists, will help ensure a positive and successful healthcare system as we move into the future.