Ralf Allikvee: Patient mobility will not bring more money to health system

18. March 2015

Patient mobility or the right of patients to choose their medical service providers will lead to the situation where private clinics with less responsibility will pick the cherries off the cake and the larger hospitals that offer universal services nationwide will have to cope with less, writes CEO of East-Tallinn Central Hospital Ralf Allikvee.

The National Audit Office, PRAXS and the World Health Organisation have proven beyond doubt that the present model of health care financing in Estonia is not sustainable.

The king is naked and the politicians’ solution for smarter redistribution of money is wishful thinking in the best and playing with the future of Estonian medicine in the worst case.

Patient mobility or the right to choose one’s medical service provider is more than an intellectual battle of thoughts between different views of the world. The health and lives of our people are at stake here. The planned system will lead to the situation where private clinics with less responsibility will pick the cherries off the cake and the larger hospitals that offer universal services nationwide will have to cope with less.

Studying waiting times for health services and possible solutions is becoming a separate science in the world. There is no irony in this statement, as decisions made on the basis of arguments or populism have a direct impact on the ca one billion euro budget of the Health Insurance Fund.

Basically, there are two ways of regulating health funds - either to change the demand or the supply.

For example, the role of the family doctors as the gatekeeper on the way to a specialist represents the regulation of demand. Adding patients to waiting lists according to the state of their health is also such a measure. For example, a three-level waiting time for scheduled treatment has been established in Australia - up to 30 days of the health of the patient is likely to deteriorate fast; 90 days if the patient’s health is not likely to deteriorate and 365 days it is unlikely to deteriorate. Estonian hospitals also practice such differentiated waiting lists within specialities, e.g. in orthopaedics and eye treatment.

The offer of medical services depends on the money received for the provision of such services, the existence of qualified doctors and technical infrastructure, i.e. hospital buildings and equipment.

The situation in Estonia is pretty good in terms of the latter. Apart from some top-notch technical achievements and hospital buildings that would serve well as museums, we have achieved the strong European average. Some of the best technology will never be available in Estonia due to our small size and there are a number of services that must be purchased from abroad.

Things get a bit more complicated when we speak about manpower. Borderless Europe, massive differences in wages, people commuting between Estonia and Finland as well as between Tartu, Tallinn and the rest of Estonia, increase the tension even further. We’re coping right now, but the trends don’t promise us anything good. 126 Estonian residents graduated from the Department of Medicine of the University of Tartu last year and only 80 of them opted for residency thereafter. This means that more than a third of our future doctors either leave Estonia or never start practising medicine.

Funding is the weakest link on the side of resources - Estonia’s health expenditure is less than 6 per cent of GDP, i.e. one of the smallest among developed countries.

Those who fight for patient mobility or, to put it bluntly, ‘buying a place in the front of the queue for jointly saved money’, proceed from the understanding that there is health insurance money left over in the Estonian health system, because doctors cannot do enough work or there isn’t enough equipment. Unfortunately, this assumption is as wrong as can be. The entire annual budget of the Health Insurance Fund is spent as planned and there is even a shortage of money.

Universal hospitals do millions of euros worth of overtime the expenses of which are no covered as a rule. For example, there cost of the treatment cases for which East-Tallinn Central Hospital received no compensation in the previous year exceeded two million euros. It’s hereby important to distinguish universal hospitals from private clinics that mostly offer niche services, usually eight hours a day, five says a week. Pursuant to law, universal hospitals that cover the entire country are basically obliged to guarantee medical services from birth to death, 24 hours a day.

Money is the main reason why the waiting lists for scheduled treatment are so long. Our hospital could increase the quantity of the services they provide by one-fifth if only they had enough money.

Then there are the attempts to create the illusion that if a patient pays for a service out of their own pocket first, it will somehow create more free funds for the medical system. The scheming of the financial world should be left to swindlers and nobody has found wealth by moving money from the back pocket to the front. Yes, the specific patient gets to the front of the queue, but the money for the provision of the service is taken from the future periods of the Health Insurance Fund, which makes future queues longer.

The third false assumption is that a one-off action on the account of the future can shorten waiting times and allow us to think that this is how it’ll always be. The price of oil will fall when there is oversupply, but it’s not possible to saturate the market for health services. The fact that the wealthiest European countries still have waiting lists is testament to this. Any temporary shortening of waiting times in one area of medicine will generally lead to an increase of waiting times in other specialities.

This means that patient mobility will not make general waiting times shorter. The principle ‘I will pay for the service myself first and then take the money back from the kitty’ is nothing else than buying yourself a place in the front of the queue for the health insurance money solidarily saved by everyone and it will only increase inequality in health. What will the politicians, who propagate patient mobility, say to people on low income who life from hand to mouth and who have no way of finding this money?

Jumping the queue with money borrowed from the future is also in conflict with the regulation of demand, i.e. the system of parallel waiting lists depending on the actual state of people’s health.

Everyone is entitled to protection of his or her health and health is a matter of the state. The primary level, the hospital network and the Health Insurance Fund are the instruments that guarantee the balanced functioning and development of the health system - from birth to death, from neonatology to geriatrics. The increased flow of money to narrow service areas puts the entire sector in jeopardy. Cross-subsidising between specialists will always occur in large hospitals. When even more cherries are taken off the cake, it will become inedible at some point.

Patient mobility may have another undesired consequence. If unlimited amounts of the Health Insurance Fund’s money will start flowing to private clinics, universal hospitals will start using the same legal back door in order to survive. Even more gaps would be planned into the waiting lists so that appointments could always be offered to people who pay ‘with their own money’ in specialities that compete with private medicine.

It is certain that such developments will make planning the expenditure of the Health Insurance Fund extremely difficult. Will liabilities as services already provided by taken in the current period with regard to the next one? In some specialities, doing this would mean that the money planned for several years could be spent in just one. And then what? It doesn’t take much to cause an avalanche, but it takes a village or a town to stop it.

Source: Postimees