Several articles in various publications have covered the Health Insurance Fund's deficit, and the main question is how the fund will manage a situation where it needs to dip into its reserves. The Health Insurance Fund's management board has discussed this issue, but have any concrete proposals reached you or the government yet regarding what the future might look like?

The Health Insurance Fund has made a few very preliminary proposals. If we think about why this kind of deficit has emerged, then I believe — just like in medicine, where treating an illness must begin with a diagnosis — the same applies to the Health Insurance Fund. We all know that prices have gone up and the cost of living has increased.

Another part of the issue is that there are expenses that are not easily trackable or clearly understood. Perhaps we should even consider changing the funding model to focus more on quality and outcomes rather than simply volume — that is, the number of tests or lab analyses performed. For instance, in the hospital system, there's a situation where the more tests and analyses are done, the more beneficial it is for the hospital. I can't blame the hospitals for that, nor the doctors — it's really about how the flow of funds has been managed up to now.

We should now start thinking about how we could improve this a bit. Some aspects should certainly remain as they are — like the current fee-for-service system — but some could shift toward outcome-based funding. That model is already in use to some extent, for example in the family doctor system. There, the outcome component could be stronger than it is now. Additionally, the family doctor system uses a capitation model, which also allows physicians to be creative in terms of managing costs — not by cutting back on tests, but in a way where it's in the doctor's interest for the patient to stay healthy. There's definitely still room for improvement here. Some services are already funded this way, but there's clearly potential to enhance the system further.

So what would quality-based funding actually mean? Essentially, that if a surgery is successful, then money is paid out?

For example, if the outcome is better, the funding would be higher — but there are many different mechanisms involved. One could be that if patient satisfaction is higher, then funding improves as well. It all stems from quality. Healthcare in Estonia is already of high quality, but that quality fluctuates and we don't have a unified monitoring system. In fact, when quality varies, money tends to slip away too, because low-quality care is always more expensive than high-quality care.

Quality-based systems always take patient feedback into account, but we can't rely solely on patient opinions. There are many components to consider — one of them is justification. Patients tend to like it when they receive a lot of tests and analyses. Research has actually shown that people who are overtreated or over-tested report higher satisfaction, but their objective health outcomes are worse. This kind of overtreatment is actually harmful to a person's health, and ultimately, we have to prioritize people's well-being above all.

One thing you've also mentioned is that you want to identify overlapping areas in the healthcare system — places where waste is happening — so that these can be eliminated and the system made more efficient. How has that gone so far? Have any such areas been identified, and if so, what are they?

These areas are generally well known to doctors. A simple example is when a family physician orders an X-ray and blood tests for a patient and identifies a problem. The patient is then referred to a specialist — sometimes even through the emergency room — which means they might see the specialist the same day. But at that specialist visit, the same tests and analyses are often repeated, simply because it's more convenient for the specialist to access the results from their own computer system and IT platform. So what's really needed is a more sensible integration of IT systems, and that's something we're currently working on.

The Health Insurance Fund has already created a mechanism to check whether, for instance, the same test has been billed twice — something that occasionally happens by mistake. Sometimes both the specialist and the family doctor order the same test. Other times, one of them forgets that the test has already been entered into the billing system and inputs it again. These checks have been in place, but until now they've been mostly manual. If we can automate them, we'll likely be able to review many more billing claims, and that's where the savings will come from.

One somewhat controversial issue that has come up concerns how family doctors have paid out or taken dividends from their private practices. In some cases, these amounts are very large — reaching up to a million euros. As we know, that money largely comes from the Health Insurance Fund. Is this something that should be reviewed? Because inevitably, if there's a shortage of funds in the Health Insurance Fund and that money ends up, so to speak, in a family doctor's pocket as dividends, is that really the best use of those resources?

In this case, we need to look at where these dividends are coming from and which family health centers are involved. The media has mentioned places like Pärnu and Narva, where there are a large number of partners involved in a single center — sometimes 13 practices, for example — which generates a sizable pool of dividends. It's also important to look at how often these dividends are paid out — is it every year or once every ten years?

The current funding model does allow family doctors, when operating normally, to save up some funds over time — maybe accumulating a larger amount over ten years or receiving a steady amount annually. That kind of dividend payout is perfectly normal.

Then there are operating costs to consider. Family health centers in Tallinn, for example, face higher rent and lease prices compared to places like Narva. Sometimes local governments help by offering very low rent or even free premises, which results in additional savings. This could also serve as an incentive for doctors to practice in smaller towns, where they might end up earning more in dividends.

At the same time, we must absolutely look at the quality of services being provided and whether dividend payments are coming at the expense of quality. For instance, are medical devices being kept up to date? Are all services being offered for which the Health Insurance Fund is paying? Can patients reach their doctor through digital services, for which the Health Insurance Fund now pays a monthly fee to clinics? These are all questions that fall under the Health Insurance Fund's responsibility — to ensure that if they're paying for a service, it's actually being provided at the family health center.

Of course, the funding model itself should be reviewed. We need to ask why dividends are being paid out — was there an excess of income, is it reasonable under the circumstances? Each center should be looked at individually to assess whether the work being done justifies the income.

Additionally, family doctors can earn extra income through various supplementary services — minor surgeries or gynecology, for example — which are in high demand. In rural areas, there are doctors like Madis Veskimägi, a well-known physician who performs many of these procedures right in his clinic. As a result, his patients don't have to travel 60 kilometers to Pärnu. And he's not the only one — we actually have many such family doctors. I think it's a very positive thing when doctors are compensated for providing such additional services, and it's entirely appropriate for them to earn more as a result.

Some family health centers also collaborate with pharmaceutical companies or participate in clinical research — often not with drug companies but with universities — and those activities bring in separate streams of income. So we also need to examine where the money is coming from. Not all of it may be taxpayer money; some may come from private services or other sources. It all has to be evaluated case by case.

Does the Health Insurance Fund actually carry out checks to ensure that the quality provided by a family health center meets the required standards?

The Health Insurance Fund conducts quality control a bit differently. They monitor whether patients on a doctor's list are being followed up for chronic conditions. For example, whether children have attended checkups and received counseling. As far as I know, the Health Insurance Fund doesn't directly monitor the business activities of family health centers, and perhaps that's something that should be discussed with them.

In reality, there aren't that many centers where the dividends are that large or paid out annually. Such oversight could certainly be implemented, but does it need to be the Health Insurance Fund doing it? Maybe it should actually fall under the Health Board's responsibility. These are discussions we still need to have.

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