1. Tartu University Clinics 1 TARTU UNIVERSITY HOSPITAL General information Structure Analysis and marketing department Contracting

2. Tartu University Clinics 2 Short history of TU Hospital In May 1804 was opened Tartu University Hospital – Clinicum Universitatis Dorpatensis University Hospital until 1940 Independent governmental hospitals whose communication with Tartu University was not formalized June 16th 1993 state roof-organization Clinicum of Tartu University was established Disputes over the connections of Clinicum and Tartu University were held in 1995-1997 Tartu University Hospital Foundation as an integral organization was established in 1998 by the Republic of Estonia, University of Tartu and city of Tartu 1999 – restructuring; January 1st 2000 new structure

3. Tartu University Clinics 3 Basic structure of the TU Hospital ClinicsMedical services Administrative services Management Board: Mr Urmas Siigur - chairman + finances Mr Mart Einasto - staff, quality, marketing,PR, IT Mr Margus Ulst - treatment, training, research Mrs Malle Keis - business, building, equipment Council / Supervisory Board: Estonian State (M.Soc) – 3 Tartu University – 3 City of Tartu - 2

4. Tartu University Clinics 4 Clinics and Medical Services

5. Tartu University Clinics 5 Basic facts (2008) I 16 clinics with ~ 940 hospital bed The number of beds has been reduced 40% since 1995 – from 1605 Per year treated: –43 500 inpatients (average length of stay 6,1 days, it has been reduced 44% since 1995 - from 10,8) –11 500 daycases –450 000 outpatient visits

6. Tartu University Clinics 6 Basic facts II Personnel 3558 Doctors 684 in 35 specialities Nurses 1169 Assistant nurses 838 Technical staff 867 620 students / 535 000 hours per year

7. Tartu University Clinics 7 Basic facts III Turnover ~ 1 800 m EEK ~ 109 m € (2008) Estonian Health Insurance Fund - 90%; Other medical institutions (family practitioners, general hospitals etc) - 4%; State budget - 2%; Out-of-pocket payments - 2%; Other income (traffic insurance etc) - 1%

8. Tartu University Clinics 8 Short history of contracting negotiations with HIF …95 – no contract, budget financing principle => 29 local HIF, chaos, intoducing of Central HIF 95…99 – first contracts, no experience, message throw mass media “HIF is indebted to hospitals” 99…05 – consolidation of hospitals and HIF; introduction of new contractas – cases and average costs. Main arguments “emergency versus elective services” 05…08 – economic growth, expansion. Main arguments “content of services, new services” 09… - cost containment, surviving

9. Tartu University Clinics 9 “Big issues” in contracting Waiting lists Expensive cases –relatively (2...10*average) and –extremely (over 1 M EEK – 6667 €) Rapidly growing specialties –LOR –Cardiology –Andrology New methods, techniques, guidelines, drugs New services

10. Tartu University Clinics 10 Eternal problem with HIF - prices Content of services in service list –Old services (renewed content) –New services Prices –…04 “negotiation based” prices –04… cost (evidence) based prices Wages Different content in different level hospitals “Political coeficients” DRG-s –Margins / differences –Exclusions

11. Tartu University Clinics 11 Analyses and Marketing department Medical statisticsMarketing

12. Tartu University Clinics 12 Analysis and Marketing Department II The main task of medical statistics department is collecting and analysing of the medical statistics to control the patient care records; to prepare statistical reports and analyses for clinics and Estonian Medical Statistics Bureau; to archive and charter medical documents; to collaborate with different registers of medical statistics;

13. Tartu University Clinics 13 Analysis and Marketing Department III The main tasks of marketing department are: contract management negotiations with health insurance fund and clinics imposing non-emergencies’ (planned patients) treating limits for clinics submitting invoices to the EHIF carry out billing on the basis of electronic care records

14. Tartu University Clinics 14 Analysis and Marketing Department IV analysing performance data, data-processing processing claims for mistakes in invoices maintaining waiting lists Patient satisfaction surveys …

15. Tartu University Clinics 15 Contracts with Health Insurance Fund 2009

16. Tartu University Clinics 16 Contracts with Health Insurance Fund

17. Tartu University Clinics 17 Contracts with Health Insurance Fund 2009

18. Tartu University Clinics 18 Treatment Invoices ~ 570 000 invoices per year The payment of ambulatory specialist care and inpatient care is based on contracts with the EHIF on the basis of the volume and average cost of cases treated in each speciality. Payment is based on service prices set out on the price list (the list of health services, established by a regulation of the Government of the Republic) All hospitals are paid the same prices; there is no adjustment for hospital characteristics such as teaching status. From 2004 - 10% of each case is reimbursed using prices based on diagnoses-related groups (DRGs) and 90% by fees for services from 2005 - DRG 50% +fee for services 50%; from 2009. DRG 70% + fee for services 30%

19. Tartu University Clinics 19 Contracting process – continuous process Preparation period in hospital (overview of the main changes and developments maid in patient treatments by medical specialties) Negotiations with health insurance fund (priorities, both side possibilities, compromises, justifications) Agreeing contract (contract is the formal ‘tip of the iceberg of a deeper relationship) Contract management Evaluation, analyses of performance data (meetings with health insurance fund once a month) Renegotiating, asking additional money with justification, good proved data, (to improve the accessibility of ambulatory care by reducing waiting times) New contract evolves from a previous contract taking into account HIF budget, pricelist changes, changes in clinics, new treatment methods,….

20. Tartu University Clinics 20 Conditions of contract for financing medical treatment 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 amounts for each of the medical professions established by the Minister of Social Affairs 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;

21. Tartu University Clinics 21 Conditions of contract for financing medical treatment many other conditions necessary for ensuring the efficient and purposeful use of health insurance funds The health insurance fund shall enter into contracts for financing medical treatment only with health care providers who maintain waiting lists pursuant to clause 56 (1) 4) of the Health Services Organisation Act and enable entry into contracts for provision of health service through the health information system.

22. Tartu University Clinics 22 Conditions of contract Our cost and volume contract covers five years, fiscal appendix is agreed for one year Large contract is subdivided into medical specialities All specialty procedures (emergency and planned; minor cases and expensive) are usually included in the one specialty contract For some services special detail rows ( heart disease surgery, deliveries, hip replacements)

23. Tartu University Clinics 23 Maximal waiting time Primary care - in the case of acute illness – 1 day - elective visit to the family doctor – 3 days Specialist-care -outpatient 6 weeks - emergency care – 1 day - acute care – 3 days - elective care – 8 months excl - joint replacements – 2,5 years - eye (cataract) surgery – 1,5 years - ear-nose-throat surgery – 2 years - cochlear implantations – 1 years - cardiac surgery – 8 months

24. Tartu University Clinics 24 Our strength in contracting process the largest provider of medical care in Estonia, there are no alternative providers for most services in our area all medical specialties are represented here In several fields (kidney, bone marrow and liver transplantation and congenital heart disease surgery) the only medical institution in Estonia

25. Tartu University Clinics 25 Main problems of contracting Exceeding contracted volumes DRG influence on treatment cost The treatment cases vary in cost in wide range (risk sharing reserves) Outpatient waiting times are longer than HIF standard