1. Introduction of the Estonian Health Insurance system and E-health
Tanel Ross
Chairman of the Management Board

2. Background Population: 1,3 million
Social health insurance coverage: 94% of population
ALE at birth 77 years (2015)
Health Expenditure (2015) 6.5 % of GDP
Financed: 13 % earmarked health insurance tax on salaries paid by employers
Member of EU since Euro-zone since

3. History of Health Insurance in Estonia
Until 1991: soviet Healthcare system
Financed from the state budget, centralized state governance
Exceptionally big number of hospitals
Important changes since 1991:
1991 health insurance law: early developments for a solidary health insurance
1992 Regional non-competing sickness funds (22 in total)
1994 Regional sickness funds coordinated by central sickness fund
Since 2001 One Estonian Health Insurance Fund (EHIF), where number of regional departments was reduced to 4
Today:
One single health insurance fund
Hospital Network: 19 facilities across Estonia, plus selected partners outside the Network (approx. 30 hospitals in total)
Over 800 primary care pracitioners

4. Estonia has made significant efforts to achieve universal health coverage
Single public insurance provider (Estonian Health Insurance Fund)
Automatic enrollment for:
children, pensioners and disabled
adult population, except those w/o formal employment/entrepreneurial activity and not registered as unemployed
Approx 96% of population covered
Financed by social insurance tax (13%) plus transfers for unemployed and students
Health expenditure app 6,5% of GDP: EHIF (70%) + OOP (ca 20%) + govt
ALE – approximately 77 years

5. Providers in Estonian health care system
Emergency care
Primary health care (every Estonian has a personal FP)
Specialized medical care
Hospitals
Outpatient specialized medical care
Dental care
Nursing care, midwives
All health care providers are independent entities operating under private law
They may belong to both public or private ownership

6. Social Insurance Board
Administrative model of Health Insurance
Ministry of Social Affairs
Unemployment
Insurance Fund
EHIF
Health Board
State Agency
of Medicines
Social Insurance Board
Contracts
Health care provider
private law, public or private
ownership

7. EHIF’s budget 2016 and 2017 (Millions EUR) Budget 2016
% of total budget
Budget 2017
EHIF's revenues
1004,40
100,00%
1114,077
100%
Healthcare services in total
740,98
73,11%
795,9
71,5%
Health promotion
1,25
0,12%
1,436
0,2%
Pharmaceuticals (outpatient)
114,45
11,29%
131,2
11,8%
Temporary incapacity for work benefit (sick leave)
118,27
11,67%
140,3
12,6%
Benefits for medical devices
9,30
0,92%
10,1
0,9%
Benefits arising from EU legislation
8,27
0,82%
9,09
Benefits for dental care services
9,63
0,95%
15,7
1,4%
Other expenditures
2,30
0,23%
2,6
0,3%
Health insurance expenditures in total
1004,45
99,11%
1106,3
99,3%
EHIF's administrative costs
9,07
0,89%
9,9
Expenditures in total
1013,52
1116,2

8. Health insurance package
Primary care (106,9 million euros, 9,6% of budget)
Specialist care (598,1 million euros, 53,6%)
Nursing care (30,7 million euros, 2,8%)
Dental care (9,6 million euros, 0,9%)
Out-patient Pharmaceuticals (131,1 million euros, 11,7%)
Medical devices (10,1 million euros, 0,9%)
Temporary incapacity to work (140,3 million euros, 12,6%)
Cross-border health care (9,09 million euros, 0,8%)

9. Challenges – comprehensive and sustainable benefits package
Insurance coverage effected by:
central uniform service and price list
capped contracts with FPs and (strategic) hospitals
Primary care (every Estonian is assigned to family practitioner):
capitation plus FFS (tests, minor ambulatory services)
QBS (mostly input, some output indicators)
Specialist care (mandatory referral from FP, free choice of provider):
out-patient – FFS, in-patient – DRG+FFS
Nursing care, both out- and in-patient (mandatory referral)
OTC pharmaceuticals – 75%/90%/100% compensation for prescripitons,
ingredient-based (max level - 2nd lowest market price)
Sick-leave benefits – 70% of salary, up to 6 months
IT: fully electronic invoicing, prescriptions and SLBs (structured data)

10. E-health and health data: infrastructure and challenges

11. Foundations of Estonian E-health
Every person has an ID-card
Political agreement to use ID card for official identification
Central data security layer via X-road
A secure authentication with ID-card or Mobile-ID
Digital signing of all medical documents
Maximum transparency: all action leave an unremovable secure trail
Coding personal data: separating personal from medical
Encrypted database and monitoring all actions
Cooperation between different databases
Patient can access and control their data, declare preferences, monitor visits and has the right to opt out from collecting data to central database –

12. HIE platform history Planning initiated
Project preparation ( )
eHealth Foundation established (2005)
eHealth Projects ( )
National HIE
2000
2002
2004
2006
2008
Funding decision by Ministry
of Economic Affairs
Electronic Health Record
Digital Images
Digital Prescription
Digital Registration

13. What kind of data do we collect today?
Centralized and other databases
Electronic Medical Records (case summary) –> all healthcare providers must send data there
Imaging database
Registries (cancer, deaths, births, drugs)
Electronic Referral database
EHIF databases
Insured people’s registry
Claims from our partners
Sick-leave benefits
E-prescription database
Service providers collect their own additional data with their own IT systems
Most data is personalized but is de-personalized for inquiries/research

14. EHIF health information is divided between two datasets regulated by law
2) Prescription database:
Physician view:
Create, revise and cancel prescriptions
Pharmacist view:
Browse prescriptions
Send purchasing information
Invoicing (prepare, review, confirm)
Patient view (via state portal):
Self-surveillance
E-Health patient portal
Set purchase authorizations
Set reading protection for physicians
Health Insurance Database where we collect data:
about the citizen
type of insurance
insurance provider (who pays social tax for this person)
about the organization who maintains the source information registry

15. How do we use big data? Short and Long Term Planning
Monitoring and Controlling
Ensuring Service Quality

16. 1. PLANNING: our database gives us a unique way of planning the budget and contracts with new prices for the following year
All planning and budgeting is done via SAP Business Warehouse (planning and reporting system)
Specific methodology for planning: according to the actual use of services and known trends and need for services
The process:
We factor in the new price in SAP,
find the new average cost for a case,
and plan the new budget and contracts (including cases per contract) based on the calculations
This enables to us compare budgets and contracts between different years by different prices and to new prices

17. 2. MONITORING and CONTROLLING
EHIF has a fast and secure channel for our partners to submit info to us (TORU)
All contractual partners of EHIF (specialized care, primary care, dental care) submit medical claims into the EHIF system
Approx 7 million claims per year
Most comprehensive and detailed collection of medical data in Estonia
One solution streamlines and simplifies the process of submission and billing
All claims make one big data collection where data quality is the priority
Data communication is electronic, structured, XML based, no paper
Quality controls for
technical aspects: is the format correct?
content: does this hospital offer services they billed for?

18. Fraud Risks
False data from doctors (about opening or prolonging sickness leave based on false info, diagnosis, procedures, number of patients in their list, personnel etc)
Forged documents from insured people (to get reimbursement/benefits, to prove payments or services, income etc)
Filing double claims
Frauds regarding pharmaceuticals (documents, price, patient's identity etc)
Patients can view their medical bills online at and state portal

19. 3. QUALITY: EHIF focuses on increasing healthcare quality by using its data for research and measuring quality on a national level
Comprehensive de-personalized data from 7 million medical claims a year is provided for researchers outside of EHIF
We also conduct research internally
EHIF’s Healthcare Quality Divison collaborates with the Healthcare Quality Indicators Advisory Board to analyze established indicators to make conclusions about the state of care in Estonia and improve quality of care
In 2016 we published the first conclusive report of our findings
Annually we measure quality indicators that we have developed in collaboration with the World Bank (using claims and presicriptions data)
All indicators are displayed on our website free of charge and can be viewed in an interactive chart which displays results about each hospital
In addition to publishing existing indicators, we work closely with medical experts and analysts to increase data quality and to develop new clinical indicators

20. Future E-health challenges in Estonia
What do we really want to achieve with our e-services?
- What is the benefit for the sector, patient and doctor?
- Personal medicine – how far can we go with personalization?
Sustainable management and financing
- How to insure that we move foward from pilot phase?
Cooperation between different databases
Data quality
Data is sent to Electronical Patient Record in different times by service providers
Old data structure -> difficult to extract and use data (e.g from text fields)
Data mining depends on the validity of invoice conduction, may need more information than just an invoice
Data mining is time consuming and expensive (medical doctor), might be automated in the future
People’s awareness of the e-services
- Do they know how to use them?

21. Thank you!