1. Ensuring financial sustainability of health system in Estonia Hannes Danilov Head of Management Board JOINT OECD AND WHO MEETING ON FINANCIAL SUSTAINABILITY OF HEALTH SYSTEMS TALLINN, ESTONIA 28-29, JUNE, 2012

2. Estonian Health Insurance Fund (EHIF) Established 2001 independent legal body (semi-public) acts under Health Insurance Law 4 geographically placed regional offices

3. Main obligations of Estonian Health Insurance Fund To public: - purchasing of high quality health care services - compensating temporary sick leave benefits - compensating prescribed medications Sustainability: - solvency of the Fund - sustainability of funding

4. Pre crisis time 2001- 2007(8) Economical growth, specially after the joining EU 2004, was from 6,7 to 10,3% per year Collecting reserves in EHIF: - solvency reserve – 6% of total budget - risk reserve – 2% of budget of health by law care benefits - surplus – difference between forecasted revenues and expenditures EHIF initiative

5. EHIF revenues, expenditures and reserves

6. Decisions made coping the crisis – dental care and nursing care Before 2009 all insured persons aged 19 and over were entitled for dental care cash benefit of 19.18 eur, but from 2009 only retired persons retained this right 15% co-insurance rate for nursing inpatient care, 2010

7. Decisions made coping the crisis – temporary sick leave benefits Sharing responsibilities between patient and employer from July 2009: - No benefits paid for the first 3 days of sickness or injury (previously only one day) - Employer pays benefits from 4 to 8 days, from 9th pays EHIF (previously employer did not participate) - Reducing benefit rate from 80% to 70%

8. Decisions made coping the crisis – reducing tariffs 2009 -Reducing all health services tariffs by 6% 2011 -Raising health services tariffs by 1% 2012 Tariffs raised to pre-crisis level

9. Key messages for EHIF -Reducing out of pocket payments for medications -Strengthening primary health care -Improving health technology assessment -Monitoring outcome indicators -Stronger oversight of capital investments in infrastructure and technology -Paying attention to improving value for money

10. EHIF expenditures and OOP for prescribed medications 2007 - 2011 Requested ATC based prescriptions since 2010 Implementing electronic prescription with prescription centre 2010 Requested offering of cheapest medication in pharmacies 2012 Promotion campaignes for public OOP has fallen 37,8% to 34,5% within last 3 years for medications Ceiling of compensation 50% compensated prescribed medications will abolish since Oct 2012 Total OOP has decreesed from 24 per cent 2006 to 19 per cent 2011

11. Stregthening primary care - better coordination of care for chronically ill patients P4P payment Financial support for recruiting second family nurse since Jan 2013 Request to be referred by family physician to specialist for chronically ill patients since Oct 2012 E-referrals, E-health IT system

12. Improving Health Technology Assessment Using pharmacoeconomical assessment of medications before including positive list since 2004 Economic evaluation of health care services before added to the benefit package since 2003 Developing health technology assessment unit in Tartu University within next 5 years. Supported by the EU structural funds

13. Monitoring outcome indicators Case-mix index by hospitals Proportion of caesarian sections from all deliveries in hospitals

14. European Health Consumer Index value for money

15. Lessons learned Assess your risks and be ready for crisis situations before the crisis Crisis time - introduce reasoned actions and try to avoid delays When you need to make cuts, try to retain balance of burden on providers and insured persons Retain sustainability of health system

16. Thank you for your attention!