Estonia

June 2006

By dr. Ruth Kalda 

The Health Services Organization Act in force since the beginning of 2002 sets out the regulatory framework for family medicine. Primary care is organized as the first level of contact with the health system. It is provided by independent family doctors contracted by the EHIF. Although family doctors are allowed to work without a contract, there are few reasons for them to operate on a purely private basis: most patients have timely access to EHIF-contracted family doctors, and few patients would be willing or able to pay for primary care.

Each family doctor has a list of registered patients. These lists cannot contain fewer than 1200 or more than 2000 patients (except in specific cases such as occur in some rural areas or on some islands). The average patient list size is 1700. Patients can change their family doctor at any time if they can find a new family doctor to take them on. The EHIF’s 2005 health care satisfaction survey shows that 14% of the population changes family doctor within a three-year

period. Most changes (35% of them) were due to people moving to a new area, but a fifth were due to dissatisfaction with the previous family doctor. Family doctors usually operate in rented premises (sometimes in facilities which used to be polyclinics), although some doctors have taken out loans to build new facilities.

The main services provided by family doctors include diagnostic procedures, treatment of general illnesses, health counseling, health promotion and disease prevention. Family doctors control most access to specialist care. Patients need a family doctor’s referral in order to see most specialists and to be admitted as a non-emergency inpatient. However, patients are able to access the following specialists directly, without a family doctor’s referral: ophthalmologists,

dermato-venereologists, gynaecologists, psychiatrists, dentists and, in case of trauma, traumatologists and surgeons. Initially, there was considerable resistance to the requirement for referrals to specialists, from both specialists and patients. This has started to change as specialists have come to understand the role of the family doctor, and after the government introduced regulations concerning specialist visits without family doctor referral. Patients now have to pay out of pocket for any visits to specialists made without referral from their family doctor.

All family doctors are required to work with at least one family nurse, even though there is a shortage of trained family nurses. Minimum practice standards (in terms of size etc.) are also specified by law and monitored by the Health Care Board and, in some cases, by the EHIF and county governments. As of 2003, every family doctor had a contract with the EHIF and a patientlist.

There are 750 members in the Estonian Society of Family Doctors; it is about 90 % of the doctors working in the primary care units. Every third year, new board is elected.  Each county has their local branches of society and representative in advisory board.  Several working groups are working in the lead of board members, to solve various problems what GP-s met in their work.  Society represents GP-s in the national level, but also tries to reach every doctor, to solve their problems.

The contents of a basic contract are agreed by the EHIF and the Estonian Society of Family Doctors. Before the start of the calendar year, the EHIF branches enter into contractual agreements with family doctors on an individual or group basis. The financial part of the contract is revised four times a year based on changes in patient lists. The model of primary care organized around family medicine is supported by the way in which family doctors are paid: a combination of a basic monthly allowance, a capitation fee per registered patient per month, some fees for services and additional payments based on distance to the nearest hospital etc. The payment system is designed to provide family doctors with incentives to take more responsibility for diagnostic services and treatment, as well as to compensate them for the financial risks associated with caring for older patients and working in remote areas. Access and quality of primary care are monitored by the Ministry of Social Affairs and the EHIF. Family doctors are required to have at least 20 visiting hours a week, and practices should be open for at least 8 hours a day.

In primary care, patients should be able to see their family doctor on the same day for acute problems; patients with chronic conditions have the right to see their family doctor within three days. Telephone surveys based on random samples of family  doctors, including a third of family doctors in each of the four regions, are carried out quarterly by the EHIF. The 2002 results show that all patients with acute problems are able to access their family doctor on the same day, and that 97% of patients with chronic conditions see their family doctor within three days. Of the latter group, 27% see the family doctor the same day, 34% the next day and 39% on the third day. There are small variations among regions and among family doctor practices of different sizes. Half of all patients with chronic conditions in small practices (<1200 patients) are able to see their family doctor on the same day, compared to only one fifth in large practices (>2000 patients). Some longer waiting times were noted for a few weeks in early spring and late autumn.

CME of the family doctors and quality development
Continuing medical education (CME) is an integral element of  the achieving and maintaining of high quality service provision in family practice. CME courses in Estonia  are mainly provided by the Faculty of Medicine of the University of Tartu in the form of one-week or one-two day- courses. During last years the Estonian Society of Family Doctors plays also more and more active role in organisation of CME courses for family doctors. The new and very popular form of the CME is distance learning using telecommunication possibilities. Although participation on courses is based on the family doctors` (FD) free decision and choice, at least 300 CME credit points are needed for recertification which takes place within every 5-year period. Beside the CME cources written report of activities, common problems and statistical analysis of visits   is needed from family doctors in order to be resertified. 

The new challenge for Estonian family doctors is moving towards continuing professional development. The first courses about how to develop personal learning plan will taken place in September 2006.

Quality incentives
During ten years of development Estonian family medicine has been well implemented in the health care system. A new challenge for family medicine in Estonia is continuous improvement of the quality of care provided by family doctors. Among the first priorities is greater attention to prevention, effective management of chronic diseases and provision more comprehensive care. To the fulfilment of these tasks, the Estonian Health Insurance Fund, the Estonian Society of Family Doctors and the Department of Family Medicine of the University of Tartu developed a new system in cooperation for the of registration of the indicators recommendable for improving the quality of the work of family doctors. The list of the indicators was included as appendix in the basic contract with family doctors. Every doctor who fulfils the stipulated requirements is granted additional funding as an incentive.

The list of indicators as an example: vaccination coverage of the children, prevention of cardiovascular disease, prevention of cervical cancer (performance of PAP-smear), prevention of breast cancer, follow-up of some chronic diseases (hypertension, diabetes type 2).

The quality development system started in 2006.

Application of quality criteria for health services for the purposes of patient management on the example of type-two diabetes (DM2)
The assessment of the management of a patient with type-two diabetes is based on the quality of the structure, the process and the outcome at the level of the patient, the service provider (professional quality), and the organisation in the provision of both general and specialised medical care.

The quality dimensions model (Øvretveit, 1992)

Input aspects	Process aspects	Outcome aspects
Patients’ level - age, gender - severity of the disease   Professional level - skills, education - field of work Organisational level - resources available - structure of the system	Entry   First contact  Assessment  Intervention  Conclusions  Leaving         _________________________________________________________         Patients’ quality process Professional quality process Management quality (quality of the organisation) process	Continuous assessment Patients’ quality result indicators   Professional quality result indicators   Quality of the organisation result indicators

1.1.       Structure: prerequisites at the level of the patient, the service provider and the organisation before entry into the healthcare system

 
1.1.1.      Patients’ level

Patients’ awareness
Patients’ awareness depends on age, gender, education and health behaviour. People who are better informed and aware know their risk factors and consult a doctor rather early to prevent the disease from developing. As the severity of the disease and the occurrence of concomitant illnesses may differ, the volume of the service provided may vary.

For the purpose of informing patients and making them more aware, it is important to:

1. ensure the right and opportunity of each patient to choose a general practitioner and be registered in the practice list (nowadays it is ensured by legal acts but some restrictions may result from having no health insurance);
    

make society aware of diabetes as one of the important health problems in the 21st century, and the existence of respective national programmes (it depends on the planning of the national health policy and setting the priorities; there is not enough awareness of the problem yet).


1.1.2.      Professional level

1.1.3.      Organisational level

1. The system of practice lists
In 2004, 757 general practitioners of the 783 who have concluded contracts with the Estonian Health Insurance Fund have a certificate of a general practitioner, i.e. 97%. 55 practice lists have not yet been opened, which does not mean that those patients have no access to family medical care, but that many practice lists exceed the allowed limits.

Each patient can choose a general practitioner and those who have not chosen a doctor are given one on a territorial principle but patients can always change their general practitioner as they wish.

2. Resources
Physicians with practice lists have concluded a contract with the Estonian Healthcare Fund, which guarantees all patients who have health insurance free consultations with doctors or nurses, and tests and analyses.
 

1.2.       Process: patients entering the healthcare system and dealing with patients

1.2.1.      Professional level

1.      Registration for an appointment
Patients enter a healthcare institution when they register for an appointment and they are dealt with when they reach reception.
 

2.      Communication
Communication with patients is an important part of dealing with patients and it starts at reception. In order to avoid any communication problems, the respective education has been introduced in the curricula of the basic education and residency of physicians.

 
3.      Documenting the provision of health services
In most cases, electronic health cards are used which meet the requirements for documentation set in the regulation. The use of electronic health cards allows for analysing the number of patients with chronic diseases, including diabetes mellitus. In reality, there is no specific electronic protocol for monitoring diabetics.
 

4.      Requirements for family practices
The minimum equipment required in family practices is set in the regulation of the Minister of Social Affairs. In order to conduct any tests or analyses necessary for diabetics, a family practice must have a sphygmomanometer, an ophthalmoscope, an ECG machine, a glucometer, urine test strips, a tuning fork for assessing vibration sensitivity, and accessories for taking blood analyses.

The accessibility of laboratory tests is generally good, many centres have their own labs and many regions use the services of a lab, the logistics of which includes all of Estonia.
 

5.      Testing
According to the Health Services Organisation Act, testing is financed by the Estonian Health Insurance Fund. Financing depends on the size of the practice list and the list of health services of the Estonian Health Insurance Fund. The following tests and procedures, which are important in the monitoring of diabetics, are included in the visit fee: checking vision and back of the eye, assessing ECG, blood sugar analysis, urine tests with strips, measuring creatinine and lipid profile. Tests for glycated hemoglobin and microalbuminuria are financed additionally.
 

6.      Clinical practice guidelines for type-two diabetes
The practice guidelines for type-two diabetes were approved by the Estonian Society of General Practitioners and the Estonian Society of Endocrinologists, and these are based on the guidelines of International Diabetes Federation European region (IDF Europe). The guidelines include a description of diabetes risk groups, diagnostic criteria, principles for the treatment and monitoring, and suggestions for referral to a specialist. There is a list of tests, analyses and procedures that need to be carried out at certain intervals. General practitioners make suggestions for treatment and renew prescriptions. Issue of prescriptions may take place after every six months at most, thus making it possible for general practitioners to see their diabetics at least twice a year. 

Family nurses consult patients on diet and physical activities, take blood sugar analyses but these activities have not been specifically regulated and the professional level of family nurses is not similar from the aspect of diabetes monitoring in all family practices.

The clinical scheme for monitoring type-two diabetics during various appointments:

 * not required for proteinuria

7.      Determination of incapacity for work or the severity of a disability
If indicated, the general practitioner fills in the documents required for awarding an incapacity for work and/or disability to a patient with a chronic disease, including diabetes, and sends these to the medical assessment committee. If the patient does not have health insurance, s/he will be deemed as insured if awarded an incapacity for work by the decision of the medical assessment committee.

1.2.2.      Organisational level

1.      Information exchange with the Health Insurance Fund
The Health Insurance Fund provides general information on analyses and examinations carried out, and issued and purchased prescriptions. General practitioners submit monthly invoices on patients’ visits, examinations and analyses to the Health Insurance Fund. The Estonian Society of General Practitioners and the Health Insurance Fund are working on a quality bonus system, which assesses, in addition to other indicators, compliance of general practitioners’ activities with the guidelines for the management of type-two diabetes.

2.      The accessibility and prices of the medicinal products and self-checking equipment
Estonia has a system of reference prices. The main medicinal products used in the treatment of diabetes are preparations based on biguanides or sulphonylurea but the discount rates of these are not equivalent. Both groups of medicinal products are important and used by different groups of patients. It is not right to put one of them in a more favourable position as it might create a situation where a preparation is chosen on the basis of its price and that preparation might not suit the treatment. Insulin has a discount rate of 100%.

The Health Insurance Fund covers the expenditure incurred by patients on glucometers and test strips in the following cases and to the following extent:

Patients’ own contribution for one prescription is 20 EEK, and the price for a glucometer and the strips must be paid in full if the patient receives less than three insulin injections a day.

1.3.       Possible further movement of patients in the healthcare system

1)      Suggesting a revisit
Revisits and continuous help are regulated by the clinical practice guidelines for diabetes. Patients have a right to visit a family nurse for checking blood sugar, consultation and drug checks.

2)      Referral to a specialist
General practitioners have the role of a “goalkeeper,” i.e. patients need a general practitioner’s referral for visiting an endocrinologist. The regulation establishes common requirements for the referral. The accessibility of endocrinologists varies between different regions in Estonia.

Diabetes is a multidisciplinary disease and diabetics may need to consult an endocrinologist or internist, a nephrologist, cardiologist, vascular surgeon, neurologist, ophthalmologist or stomatologist. There is no referral required for a stomatologist’s or an ophthalmologist’s appointment.

Patients must pay a visit fee when visiting specialists and for the whole appointment with and treatment from a stomatologist. It is possible to visit other specialists without a referral as well but then the visit fee is higher and all the medical investigations made must be paid for by the patient.

3)      Feedback
In the case of referrals, feedback from the specialists is sent to general practitioners, except in cases when patients can visit a specialist without a referral (stomatologist, ophthalmologist).

4)      Purchase of medicinal products
The network of pharmacies is good and well-accessible but the prices for medicinal products vary a lot as these have not been regulated by the state.

5)      Hospital
General practitioners refer patients to hospital in special cases only or patients are taken to hospital by ambulance. Type-two diabetes requires planned hospital treatment very rarely. Indications for hospital treatment have not been determined in the clinical practice guidelines. If patients need planned hospital treatment they will need a referral and approval from the department head.

6)      Accessibility of diabetes nurse and foot treatment
The Health Insurance Fund pays for the foot treatment of diabetics. Thus, the financial accessibility of foot treatment is ensured but the number of places patients can receive foot treatment poses a problem – such facilities exist only in Tallinn, Tartu and Viljandi.

7)      Home nursing
The accessibility of home nursing varies from region to region in Estonia. If necessary, general practitioners can refer patients to home nursing if such a service provider operates in the area. The service is paid for by the Health Insurance Fund – general practitioners do not pay for that.

8)      Social sphere and helping devices
If required, a general practitioner contacts a social worker or informs him/her of a person who needs assistance and submits a notice for the application for helping devices, if a patient has a disability due to the disease.

9)      Rehabilitation
Today, Estonia has no diabetes centres where people receive combined services. General practitioners have been given no resources for the rehabilitation of patients with chronic diseases, including diabetics.

10)  Accessibility of medical care outside office hours of general practitioners
Patients can ask for help from emergency medical departments of hospitals or paramedics if they need it outside office hours of general practitioners.
 

1.4.       Outcome

1.4.1.      Outcome at patients’ level
The most important outcome for a patient is improvements in their quality of life. In addition to quality of life, the following indicators may be used for assessing the outcome of the treatment of diabetics: patient satisfaction with the service, lack of complications, ability to work, self-checks of blood sugar and compliance with treatment regime.

1.4.2.      Outcome at professional level
At the professional level, several indicators reflecting the outcome and process of management may be chosen. After analysing the outcome, the data should be compared to official published data or valid standards or other providers of diabetes management. If required, further education sessions should be conducted in order to eliminate any shortcomings and specific plans should be made to improve the outcome.

Examples of quality improvement and monitoring indicators:

Measure	Calculate
Intermediate outcome
HbA1c	Percentage of patients whose HbA1c is >7.5 and >6.5%
Elimination rate of albumin	Percentage of patients with abnormal rate of elimination
Eye damage	Percentage of patients with damage to retina
Final outcome
Amputations above the knee	No. of cases
Infarctions	No. of cases
Strokes	No. of cases
Ulcers on the feet	No. of cases
Checks on risk factors
Hypertension	Percentage of patients whose blood pressure is ?140/85 mmHg
Smoking	Percentage of patients who smoke
Care
Eye checks	Percentage of patients checked within a year
Education	Percentage of patients who have received education within a year
Check-up of feet	Percentage of patients checked within a year
Eye checks	Percentage of patients checked within a year

 
1.4.3.      Outcome at organisational level
The following indicators are the most important outcome at the organisational level:

1.5.       Opportunities for change in improving the quality of diabetes management
Indications for referral to specialists are listed in the practice guidelines for DM2. Accessibility of specialists needs more specific assessment. General practitioners are of the opinion that patients need education on diabetes (diet, injections, foot care, physical activity) but that is not accessible. The population needs to be made more aware of the risk factors for diabetes, the nature of the disease and of the methods for prevention of the risk and disease.

1. The education of physicians and nurses is conducted according to the accredited education programmes in Estonia.
    
2. Establishing the fields of work for general practitioners and family nurses.
   Both of the fields of work have been determined in the general practitioners’ work instruction established with the regulation of the Minister of Social Affairs. According to the general practitioners’ work instruction, the fields of work for general practitioners include the following:
   During the times outside the office hours of physicians, patients can turn to emergency departments at the hospitals or paramedics.
   • promotion of health and prevention of diseases, including assessment of health risks, medical examination, individual health education, medical consultation, immunisation and screening;
   • diagnosis and treatment of patients;
   • referring to active treatment or nursing care in cooperation with specialists and nurses;
   • team work – cooperation between general practitioners and family nurses.
      
3. Accessibility of general and specialised medical care – regulated by legal acts.
   The results of the studies carried out by the Estonian Health Insurance Fund have indicated that the accessibility of general medical care is good and complies with the requirements set in the regulation. The accessibility of specialised medical care varies between different regions in Estonia. Endocrinologists work in bigger population centres and endocrinologists or internists work in the counties. The requirement of the Health Insurance Fund for the accessibility of specialised medical care is followed in general.
    
4. Continuity.
   Continuity in the monitoring of patients is ensured by the practice list principle. General practitioners have good opportunities for prevention as 50 to 60 percent of the people in their practice lists come to a consultation with them within a year.

• 300 test strips a year for children under 18 years of age and pregnant women
• 250 test strips a year for type-two diabetics who receive 3 insulin injections a day and for type-one diabetics
• Screening of risk groups
• Improvement in diagnostics
• Possible quality indicators

1. reduction in the prices/costs of services, especially for the treatment of vascular complications, and
    
2. reduction in costs incurred per patient
3. For the purposes of ensuring the monitoring and treatment quality for diabetics, family practices should have at least two nurses but the statistics indicate that there are just 0.8 nurses per general practitioner. Thus, the team helping general practitioners is small.
    
4. We have no information on the number and age structure of diabetics. We need a national diabetes programme, which would include prevention and respective calculations on the possible success of prevention methods.
    
5. The risk groups for DM2 are listed in the current practice guidelines and it would be necessary to register and analyse the outcome systematically. It would be possible to prevent the disease from developing if the risk groups were provided with thorough consultation and purposeful assessment but that would require large time and labour resources. Most of that could be done by a diabetics nurse but laying such a huge responsibility on the shoulders of a family nurse is impossible with the current work arrangements. Accessibility of services by a qualified diabetics nurse is a problem.
    
6. Specialised endocrinology centres exist in larger cities – Tallinn and Tartu. The development plan for the specialty of a diabetics nurse was approved by Regulation No. 99 of the Minister of Social Affairs from the 16th of July 2002 and according to that document, Estonia needs 15 diabetics nurses who have received special education.
    
7. Early diagnostics and treatment may increase the expenditure at first but the profit will be visible within 10 to 15 years.
    
8. It would be necessary to devise a structural electronic reminding and monitoring system for monitoring diabetes.
    
9. Calculations reveal that in reality, it is not possible to follow the practice guidelines for type-two diabetes due to the financing model currently in use.

 

- on Estonian health statistics