1 Structural changes in Finnish health care basics of current structure National Project and other...
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1 Structural changes in Finnish health care • basics of current structure • National Project and other ongoing changes • expected changes as extrapolated from challenges • evaluation, the ingredient too often absent
1 Structural changes in Finnish health care basics of current structure National Project and other ongoing changes expected changes as extrapolated from
1 Structural changes in Finnish health care basics of current
structure National Project and other ongoing changes expected
changes as extrapolated from challenges evaluation, the ingredient
too often absent
Slide 2
2 Outlines of current structure most Finnish health care is
public health care is owned and managed by municipalities and their
unions: shared management facilitates the balancing of marginal
utilities (or, better, should do so) shared ownership provides a
natural platform integration of services (or, better, should do
so)
Slide 3
3 Integration of health care institutions university hospital
level (3 o ) hospital district level (2 o ) community level (1 o )
primary education health care social welfare Martti Kekomki
division of labor regionalization balanced allocations
Slide 4
4 Numbers of actors five university hospitals and their five
special recruitment areas (ca. 1 mio each) twenty full service
hospital districts over 260 health centers over 400 municipalities
(~ 400 health policies)
Slide 5
5 The most important current monopolies pediatric cardiac
surgery solid organ transplantations certain rare neoplasms
Slide 6
6 Government money norms and rules monitoring municipalities
hospitals health center (primary care) university hospitals
research, education
Slide 7
7 SW-analysis of the traditional model Strengths: stable, thus
predictable; trustworth, thus less bureaucratic; cheap, thus
cost-efficient; controlled by local patients, thus responsible;
Weaknesses: slow to change, provides little choice, lacks
incentives, unresponsive, weakly integrated
Slide 8
8 Changes with opposing directions: 1a. centralization bringing
all regional hospital services under one single management (HDHU,
Helsinki) seeking opportunities for a prudent division of labor
(some small hospital districts) setting recommendations for minimum
annual rates of certain procedures
Slide 9
9 Changes with opposing directions: 1b. centralization creating
new public-private partnerships into selected areas (Coxa Ltd,
Tampere) creating process-oriented (instead of functional)
organizations transgressing traditional clinical departments
Slide 10
10 Changes with opposing directions: 1c. centralization
increasing the size of PHC institutions reducing the number of PHC
emergency units (several examples)
Slide 11
11 Changes with opposing directions: 2a. decentralization
bringing PHC and basic acute hospital services under single
management (health care districts; scattered experiments) forming
independent revenue units within hospitals (laboratory services,
imaging)
Slide 12
12 Changes with opposing directions: 2b. decentralization
forming hospital-owned corporations (capital management, laundry)
outsourcing of some services (parts of ICT)
Slide 13
13 National Salvage Project 2001- To narrow the growing gap
between demand and supply of services, national focus on labor
(education, re-education); reassessment of inter-professional
division of labor; improving managerial skills; emphasis on chains;
EBM; HTA; and ITC guarantee of access (3 d - 3 w - 3-6 mths)
centralization, cooperation, new incentives
Slide 14
14 NSP: Impact on university hospitals basic training: more
medical students : from nurses to MDs programs specialization: more
training outside UHs research: increasing impact on health services
research, clinical outcomes analysis, less money to basic research
incentives: private evening clinics
Slide 15
15 Problems to be answered next (in part by structural
changes): how to create effective insurance pools (effective:
expert, competent, able to buffer the stochastic nature of service
demand) improve service quality assess systematically the long-term
results improve service chain management
Slide 16
16 Increasing the size of risk pools municipalities risk
hospitals, public & private pool capitation by risk profile,
benefit package and historical use service flow
Slide 17
17 Increasing risk pools Improves technical efficiency (through
applying market forces) allocative efficiency (through applying
HTA- knowledge) predictability of municipal budgeting (by
increasing the size of risk pools) equity between municipals (by
applying historical volume indicators)
Slide 18
18 Increasing risk pools does not interfere with local autonomy
because the integration of service is adjusted locally politically
it is, however, impossible because it poses a threat to dining and
wining routines
Slide 19
19 Integration of health care institutions university hospital
level (3 o ) hospital district level (2 o ) community level (1 o )
primary education health care social welfare Martti Kekomki
division of labor regionalization balanced allocations
Slide 20
20 Enhancing service quality: the three steps to be taken
defining quality axis and constituency making quality explicit and
measurable linking quality measures to everyday function and data
collection (EPR)
Slide 21
21 Nr 1 Finnish quality initiative risk-adjusted standard
mortality ratios (SMR) of all national ICUs, which deploys APACHE
III diagnoses and SAPS risk calculation covers now over 100 000 ICU
admissions secret, private, voluntary, commercial and international
more at www.intensium.fi
Slide 22
22 Quality and costs of Finnish ICUs 1998 and 2001
Slide 23
23 Conclusions care quality in ICU is measurable over time,
quality may improve, background factors are yet to be explored
benchmarking is effective to promote better quality improved
quality is compatible with controlled costs
Slide 24
24 Focus on effectiveness (instead of efficacy) pros: measures
health change across the intervention area of use: chronic
conditions contras: no controls, relies on the natural course not
applicable to acute conditions (cf. ICU)
Slide 25
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Slide 26
26 HRQoL of back pain patients before and after a neurosurgical
intervention
Slide 27
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Slide 28
28 15D-profiles in cataract patients before (green) and after
(red) the operation as compared with age-adjusted normal population
(blue)
Slide 29
29 Health related quality of life in patients with esophageal
cancer
Slide 30
30 Conclusions a systematic measurement of effectiveness and
cost-effectiveness should be mandatory in the future data feeding
should be automatic (EPR) follow-up should be extended to years
information gained should start guiding allocative (political)
decisions
Slide 31
31 Evaluation, the missing ingredient to be evaluated,
examples: practices: pharyngeal tonsillectomy service provision:
private off-hour activities allocation: 15-D measures as guides
skills: MDs and management division of labor: nurse practitioners
ICT: still a paradox or something more?
Slide 32
32 Endpiece missing: a new strong culture, where the future
vision is clear and shared by all counterparts contracting systems
are modern measuring instruments are in place and used good
performance is rewarded nothing is done without evaluation thus far
most of this is lacking...