5.1. The health care system

The Estonian health care system is governed by the Ministry of Social Affairs. It involves several actors, including the Health Board, formed in 2010, and the Estonian Health Insurance Fund (EHIF). Health care funding is principally through SHI, which covers approximately 95% of the population. Contributions are related to employment, with non-contributing individuals (such as children and pensioners) representing almost half of the insured population. SHI accounted for 69.1% of total health expenditure in 2012, complemented by taxation (10.8%) and OOP payments (18.4%) (WHO, 2014). In 2012, health expenditure was 5.9% of GDP. OOP payments are mainly for pharmaceuticals and dental care.

The EHIF is the main purchaser of health care services. The Ministry of Social Affairs is responsible for financing emergency care for uninsured people, ambulance services and public health programmes, funded from the state budget. The role of municipalities in health financing is small (Couffinhal & Habicht, 2005; Habicht, 2008; Habicht & Habicht, 2008). EHIF funds are collected centrally to balance regional disparities in income. Most health care funds are allocated to four regional EHIF departments; pharmaceutical and temporary sick leave benefits are administered centrally, as is a small fraction for selected expensive or infrequent procedures such as bone marrow transplants, peritoneal dialysis and some oncology and haematological treatments.

The EHIF contracts with licensed providers in primary care, specialist outpatient and inpatient care. These are typically public sector providers although contracting with licensed private providers is possible. General conditions are negotiated with provider associations such as the Society of Family Physicians and the Hospital Association, for a period of five years. Individual provider contracts determine service volumes and total costs by specialty.

Citizens have free choice of GP, with whom they register. GPs principally have a gatekeeping function, with direct access to specialists granted for a small number of specialties and follow-up consultation for a chronic disease.

GPs are paid through a combination of basic allowance, capitation fee, and fee-for-service, with an additional compensation for those practising in more remote areas.

Hospitals are owned by the state, local government and other public organizations; they provide outpatient and inpatient services (Government of the Republic of Estonia, 2002). Payment is on the basis of DRGs, implemented from 2004 and complementing fee-for-service payments.

5.2. Approaches to chronic disease management

As noted above, a key component of the Estonian health care system is the central role of GPs in overall patient management and care coordination. This is accompanied by well-developed information systems with the GP as principal holder of patient data on all medical services, including hospital care. Overall, there are three main forms of chronic disease management in Estonia: quality management in primary health care; chronic disease management at the interface between primary and secondary care; and other activities within primary care (for all other diseases).

5.3. A patient journey

This section describes the journey of two hypothetical typical patients with co-morbid chronic disease in the Estonian health care system.

(A) A 54-year-old woman with type 2 diabetes and COPD who has a leg ulcer and moderate retinopathy. The patient is slightly overweight (BMI of 27). She has been unemployed for three years and receives social assistance benefits; she lives on her own.

The patient is covered by social insurance and has direct and free access to a GP. She also has free access to specialist care but needs a GP referral for that.

Thus, the first diagnosis of both diabetes and COPD generally comes from the patient’s GP, according to national diagnosis and treatment guidelines. Both diagnosed diseases can be managed solely by the GP, but given the evident disease severity and co-morbidities, it is likely that the patient will be referred to an endocrinologist and pulmonologist. The specialist appointment is generally made by the patient, but for the patient in this case study, it is more likely made by the GP or a nurse in the practice.

Depending on the disease severity assessment by the specialist, the patient can be referred for hospitalization, scheduled for routine treatment in ambulatory specialist care or referred back to GP for treatment with a verified diagnosis and specialist input. Regardless of the next steps for treatment, all consultation results are channelled back to the GP.

The patient described in this case study is most likely to remain under the care of both the GP and an endocrinologist. The GP coordinates the patient’s overall treatment and the primary management of diabetes, and oversees to some degree the follow-up of specialist care, for example, by providing reminders of specialist consultations. The GP also refers the patient to nurse-led ‘foot clinics’ while the specialist schedules follow-up visits for specialist care if needed. The specialist may also refer the patient to any other specialist although this is generally performed by the GP and the information is shared among providers.

The social assistance benefit in this case is most likely a form of disability benefit requested for the patient by the GP. Both GP and specialist may contact social care workers to ask that the patient be considered for social care services, although this is most likely made by the GP. The same also applies to referrals for rehabilitation services. A daily lifestyle consultation is provided by the GP or primary care nurse and is supported by disease-specific lifestyle advice from an endocrinologist and pulmonologist (and other specialists if need be).

Overall, the allocation of treatment responsibilities between GP and specialist is largely dependent on specific aspects of the disease and patient preferences.

(B) A 76-year-old retired engineer with chronic heart failure, severe asthma and high blood pressure. He lives with his 73-year-old wife who cares for him, while herself suffering from arthritis. They live on the third floor in a housing block and are increasingly housebound due to their illness. They are determined to remain independent; their grandson, who lives nearby, does the daily shopping for them.

Both husband and wife are covered by health insurance due to their age and have free access to the health care system.

The first diagnoses are generally made by the GP who manages their day-to-day treatment. Diagnosis and treatment are coordinated according to respective guidelines, with diagnosis verified during a specialist consultation which is also used to fine-tune the treatment, incorporating specialist expertise and additional testing in specialist care. The patient may be admitted to hospital for further testing and treatment ‘calibration’. Selection of a specific ward depends on which disease is currently affecting patient’s health the most. During hospitalization, treatments provided by cardiologists or pulmonologists will be coordinated by the main treating doctor. Follow-up visits after hospitalization are scheduled before discharge. All relevant data from specialist consultations are channelled back to the GP, indicating whether nursing or social care may be needed by the patient.

Patient management on the primary care level could include regular visits by a primary care nurse and GP, if the patient is not able to visit the GP practice in person and their health situation calls for home visits. The couple’s grandson could receive financial support from the social care system for the care he provides to his grandparents, in addition to support from a trained social worker or home nurse.

5.4. Summary and conclusion

There is currently no explicit strategy in Estonia that fully encompasses the systematic management of chronic diseases. However, elements of such a vision are emerging, involving four main components: a central role of GPs; the development of treatment guidelines by medical specialties; the strategic development of plans for specialties; and the development of care centres for selected conditions.

Thus, one of the most important reforms in the Estonian health system has been the establishment of the GP system as the cornerstone for health care delivery, with GPs acting as gatekeepers to specialist care and the coordinator of care for their patients, supported by a well-developed information system and elements of pay-for-performance for the management of hypertension and type 2 diabetes.

Second, treatment guidelines as developed by medical associations (specialties) in cooperation with EHIF form widely accepted guides for conditions such as diabetes, chronic heart disease, multiple sclerosis and others. These also include so-called ‘specialty specific activity guidelines’, such as activity guidelines for home care nurses and primary health care nurses, both of which addressing the management of chronic diseases through for example stipulating the need for proactive patient follow-up, primary health care teams and coordination of activities with social care and other medical specialties.

Third, there are strategic development plans for specialties, for example, for primary health care nursing, home care nursing and GPs of relevance for the management of chronic disease such as improving and coordinating patient access to primary, secondary and tertiary health care, rehabilitation and social care.

Finally, care centres for conditions such as multiple sclerosis and type 2 diabetes build around acute hospital care units in central hospitals by adding chronic disease management and rehabilitation options and providing links with patient organizations and social care.

Overall, these four components can be seen to form a strong basis for the further development of chronic disease management in Estonia; however there remains considerable room for the further advancement of coordination and targeted action to uncover its full potential.