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Estonian Health Insurance Fund 22.10.2009 Annes Ulm Estonian Health Insurance Fund (EHIF) Mission The mission of the EHIF is to ensure the availability of health insurance benefits to people, as well as the sustainability of health insurance system . Vision

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estonian health insurance fund

Estonian Health Insurance Fund

22.10.2009

Annes Ulm

estonian health insurance fund ehif
Estonian Health Insurance Fund (EHIF)
  • Mission
  • The mission of the EHIF is to ensure the availability of health insurance benefits to people, as well as the sustainability of health insurance system .
  • Vision
  • The vision of the EHIF is to create a sense of security in people concerning their potential health problems and resolution thereof.
functions
Functions
  • The Health Insurance Fund is a legal person in public law. The Estonian Health Insurance Fund has been registered on August 30, 2002 in the National Register of Central and Local Government Agencies, registry code no. 74000091.
  • The supreme body of the Health Insurance Fund is the Supervisory Board.
  • In order to provide health insurance benefits, the Health Insurance Fund:
  • 1) manages health insurance by ensuring the effective and purposeful use of health insurance money;
  • 2) performs functions provided for by the Health Insurance Act of the Republic of Estonia and other legislative provisions;
  • 3) maintain the database necessary for providing health insurance benefits and for the performance of other functions provided for by this Act;
  • 4) examines the quality and necessity of services partially or fully compensated for by the Health Insurance Fund;
  • 5) manages the performance of the international agreements concerning health insurance and the Health Insurance Fund;
  • 6) participates in the planning of health care and gives opinions on the drafts of legislative provisions and of international agreements relating to the Health Insurance Fund and health insurance;
  • 7) gives advice about issues related to health insurance. 
goals of estonian health care system
Goals of Estonian health care system
  • Safety – scope and availability of medical services
  • Social protection – health insurance availability in case of healt risk appears
  • People health improvement
slide6

Estonian Republic:

Area: 45 227 km²

Administrativeregions: 15 counties

Head of State: President

Gross domesticproduct (GDP) at currentprices, millionkroons:

2008 251 492.8    

2nd quarter 2009 53 941.6

slide7

Population - 1 367 000 sept 2008Statistics Estonia ,

Insuredpersons - 1 281 00031.12.2008EHIF

Percentage of theinsuredpersons - 95%

slide8

EMPLOYEE

Insured person

Funding scheme

EMPLOYER

210EEK

PERSONAL INCOME TAX

1000EEK

SALARY

790EEK

DISPOSABLE INCOME OF EMPLOYEE

24EEK

BENEFIT FOR TEMPORARY INCAPACITY FOR WORK

EHIF pays to insured person, who loses income subject to social tax

330EEK

SOCIAL TAX (33%) PAID BY EMPLOYER

4EEK

Dental care benefit,

Supplementary benefit

for pharmaceuticals,

Preventive activity etc.

COST-SHARING

BY PATIENT

The visit fee for specialised medical care and

home visit by family physician is up to 50kr,

Hospital bed days fee.

Pharmacceuticals distributed at a discount etc.

200EEK

ALLOCATED FOR PENSION

INSURANCE

130EEK

ALLOCATED FOR HEALTH INSURANCE

14 EEK

MEDICINAL PRODUCTS SUBJECT TO

DISCOUNT .

Pharmacy sells pharmaceuticals at a discount.

According to prescriptions EHIF compensates the

discount to pharmacy.

88 EEK

HEALTH SERVICES

EHIF will cover costs to health care providers in accordance

with concluded agreement.

The cost of health care services is multiplication of cases and the prices.

HEALTH INSURANCE FUND

slide9

Health Insurance and co-operation with

Family Physician

Employee signs an employment agreement

Employer

Employee/civil servant

Family phisican makes decison and

informs individual

It is possible to register with a family

physician by submitting an application

to the physician selected.

Information concering insured persons s

shall be provided to EHIF

If necessary physician issues

prescription or certificate of

incapacity for work

Family physician

Is the first person to consult with in

the case of illness

Health Insurance

Fund

Family physician submits new applications to the HIF

Medical examinations

According to capitation fee scheme the

HIF is paying the

remuneration to family phisician

Treatment of patient

If necessary patient will consult with

medical specialist

Using resources of fund for examinations and tests

the HIF compensates medical examinations.

priority of health care service
Priority of health care service

Government health care expenditures

Total costs of

government

Government health care expenditures

=

X

GDP

GDP

Total costs of

government

Context

Priority

Estonia 3,7%

EU 6,8%

EU new MS 4,6%

Estonia 34%

EU 46%

EU new MS40%

Estonia11,3%

EU 14,5%

EU new MS 11,5%

Source: Joseph Kutzin, Presentation on WHO Regional Committee for Europe, 56th Session, 13 September 2006, Copenhagen, Denmarkhttp://www.euro.who.int/Document/RC56/ebd01.pdf

principle of solidarity
Principle of solidarity
  • The Health Insurance Fund covers the costs of health services required by the person in case of illness regadless of the amount of social tax paid
  • The fund uses the social tax paid for working population
  • Countribution (social tax) is not assumed: a person under 19 years of age, a person receiving state pension granted in Estonia,a pregnant woman etc.
example of principle of solidarity 2006
Example of principle of solidarity (2006)

Source: Võrk A, LEU ja haigekassa andmetel

health insurance expenditures in estonia
Health insurance expenditures in Estonia (%)

Population 10% -make use of 72% of total budget

Pupulation 5%- make use of 56% of total budget

Population 1%- make use of 31% of total budget

Population

Expenditures

Source: Habicht J, Thetloff M, Kiivet R. Kindlustatud isikute suured kulud tervishoiuteenustele. Eesti Arst 2001;80(9):395

expensis per one insured person eek
Expensis per one insured person (EEK):
  • 7881 total expensis, includes:
  • 5331 EEK health care service;
  • 877 EEK benefits for pharmaceuticals;
  • 1508 EEK benefits for temporary incapacity for work;
  • 165 EEK dental care, preventive activity etc.
health insurance benefits
Health insurance benefits
  • Non-cash benefits –
  • health care service, pharmaceuticals,medical device – EHIF pays related costs
  • Cash benefits –
  • temporary incapacity for work,supplementary benefit for pharmaceuticals, dental care of adults – EHIF pays cash benefit directly to insured person
planning activity
Planning activity
  • Previously used health care services by insured people.
  • Planned next year technological innovations.
  • Assumed health care services demand for next year.
  • Next year price list of health care services.
  • Preferences of patients and physicians.
  • Compilation of next year budget.
  • EHIF signs an agreement with partner institutions.
slide25

Combat between Health Insurance Fund and physicians

Patient: ”Before they get the picture who is stronger, I am already disabled” Gori (Estonian caricaturist, 80 years ago)

….any changes since than?

health insurance act 35 contract for financing medical treatment
Health insurance act:§ 35. Contract for financing medical treatment
  • (1) By a contract for financing medical treatment, the health insurance fund assumes the obligation of an insured person to pay for the provision of health services under the conditions provided for in the contract and in legislation.
  • (2) A contract for financing medical treatment is a contract under public law. The provisions of Chapter 7 of the Administrative Procedure Act together with the specifications provided by this Act apply to contracts for financing medical treatment.
36 entry into contract for financing medical treatment 1
§ 36. Entry into contract for financing medical treatment (1)
  • The health insurance fund enters into a contract for financing medical treatment with a health care provider or providers.
  • (2) The health insurance fund is not required to enter into a contract for financing medical treatment with all health care providers.
  • (3) The health insurance fund has the right to enter into a contract for financing medical treatment with health care providers located in foreign states. The reference prices and limits provided for in the list of health services apply to a contract for financing medical treatment which is entered into with a health care provider located in a foreign state if the health insurance fund undertakes to assume the obligation to pay for the provision of a health service entered in the list of health services.
36 entry into contract for financing medical treatment 2
§ 36. Entry into contract for financing medical treatment (2)
  • (4) In order for a decision to be made on entry into a contract for financing medical treatment and on the term of the contract, the health insurance fund shall take into account the following circumstances:
  • the need of the insured persons for the service, and the availability of the service;
  • the quality of and conditions for the provision of the service;
36 entry into contract for financing medical treatment 230
§ 36. Entry into contract for financing medical treatment (2)
  • the price of the service;
  • the possibility of the service being provided in accordance with the standard conditions of accommodation;
36 entry into contract for financing medical treatment 3
§ 36. Entry into contract for financing medical treatment (3)
  • 5) the maximum number of health care providers providing the health service;
  • 6) figures regarding the average density of provision of the health service;
  • 7) developments in national health policy;
  • 8) whether the health care provider has performed previous contracts for financing medical treatment or other similar contracts as required;
  • 9) the existence or absence of tax arrears and the general financial situation of the health care provider;
  • 10) compliance with legislation regulating health insurance and health by the health care provider or the employer thereof.
37 conditions of contract for financing medical treatment 1
§ 37. Conditions of contract for financing medical treatment (1)
  • The following conditions shall be agreed upon in a contract for financing medical treatment:
  • 1) the term of the contract;
  • 2) the amount of obligations of insured persons assumed by the health insurance fund during a specific period of time and the total amount of obligations, and, if necessary, amounts for each of the medical professions established by the Minister of Social Affairs or amounts calculated on any other basis;
  • 3) the price payable for the provision of the health service, taking into consideration the reference price and limit provided for in the list of health services;
  • 4) the minimum volume of health services provided;
  • 5) a list of health care professionals who provide health services for which the payment obligation is assumed by the health insurance fund, and the procedure for giving notice of amendment of the list and for co-ordinating the amendments with the health insurance fund;
  • 6) the number of hours in a period of time during which the health care provider is required to provide health services to insured persons;
  • 7) the term during which the health care provider is required to submit information to the health insurance fund concerning the assumption of obligations to pay for health services provided to insured persons;
37 conditions of contract for financing medical treatment 2
§ 37. Conditions of contract for financing medical treatment (2)
  • 8) cases where assumption of the payment obligation of an insured person is contingent upon prior written approval from the health insurance fund;
  • 9) cases where the parties have the right unilaterally to terminate or amend the contract or to suspend performance of the contract in part or in full;
  • 10) the frequency with which information is to be submitted to the health insurance fund concerning waiting lists and the services provided, and the composition of the information to be submitted;
  • 11) the procedure and term for giving notice of health services provided to insured persons outside the waiting list;
  • 12) the scope of the reporting obligation of the health care provider and the obligation to submit information concerning insured persons, and the composition of the information to be submitted;
  • 13) the indicators of the quality and efficacy of the health services;
  • 14) the liability of the parties upon violation of the contract;
  • 15) other conditions necessary for ensuring the efficient and purposeful use of health insurance funds.