This presentation was made by Kersti Esnar, Estonia, at the 3rd Health Systems Joint Network meeting for Central, Eastern and South-eastern European Countries held in Vilnius, Lithuania, on 25-26 April 2019

1. Performance
measurement in
Estonia
Kersti Esnar
Head of health care resources
25.04.2019

2. Share of health care expenditure of
GDP

3. Total health expenditure (2017),
6,4% from GDP
• Health Insurance Fund ~ 65%
• State Budget ~ 9%
• OOP ~23%
• Municipalities ~1%
• Private insurance ~ 0,2%
• Other ~ 2%

4. Health insurance system in Estonia
• Social health insurance
• Mandatory
• Based on solidarity
• Coverage 94,5% of the population
• Social tax paid by all employers (payroll tax)
proportional as a flat 13% on salaries
• Additional allocation from state budget to
health insurance budget for non-working
pensioners (2018)
• Main financing organization is Estonian Health
Insurance Fund (EHIF)

5. Performance measures
Areas were indicators are set
• National Health Plan
• In primary health care
• In specialist health care

6. National Health Plan 2009 - 2020

8. The general organization of the
primary health care system
• Family physician (FP) is the first contact for a
patient within the health care system, who is
responsible for both prevention and treatment
and, if needed, refers the patient to the
appropriate specialist or uses e-consultation.
• Specialist care is accessed via family physician.
Family physicians send their patients to medical
specialists based on clinical assessment.
• Referral is mandatory on all specialties except:
Gynecologist, Psychiatrist,
Dermatovenerologist, Ophthalmologist

9. PHC team
• The PHC team consists of family physician,
family nurse and assistant.
• Recruiting of the second family nurse is
encouraged and supported by special
allowance.
• PHC is organized based on the practice list of
the physician
• If the FP works in PHC centre then the team
consists additional members: physiotherapist,
midwife, home nurse and administrative

10. In 2018
•793 practice lists
•450 service providers
•41% of the lists work as solo-practices, 59% as
group practices (21% in practices with 6 or more
lists)
•average size of the practice is 1561 patients

11. Strategic purchasing principles for
primary care
• Capitation – age adjusted monthly payment for basic services (lab
costs, medical and non-medical equipment and devices, medicines,
office and management costs)
• Basic allowance – lump sum for premises, transportation, training, IT
interface
• Fee for services - additional fund to cover the agreed list of diagnostic
and therapeutic services and procedures. Same prices as in specialist
care.
 Investigation Fund – 39-42% of capitation
 Therapy Fund – 3% of capitation, for health centre 10%
of capitation
 Operations Fund – no cap
• Allowances
 Second family nurse (lump sum covering salary, share
of premises and equipment)
 Performance Pay (QBS)
 Distance allowance

12. PHC payment scheme proportion in
2018
Capitation
54.6%
Basic
Allowance
11.6%
Investigation
Fund
21.1%
Therapy Fund
1.0%
Activity Fund
0.9%
Second family
nurse
6.6%
QBS
3.3%
Distance allowance 0.5%
Overtime work
0.3%

13. Quality bonus system (QBS)
The goal of the quality system is to motivate family
physicians to work actively on:
• Prevention
• Stopping the spread of infections diseases
• Monitor patients with chronic conditions more
effectively
• Providing insured patients with a wider set of
services.
The system of quality indicators helps the family
physicians’ analyze their own activities, compare
their results to others, seek out fields that need more
development.

14. QBS
• Performance pay introduced in 2006.
• Participation in QBS is mandatory since
2016.
• Complementary practice based quality
management system introduced since 2016.
• Focus shifted from awarding bonus points for
single activities to a “full package” approach.
• From 2016 19 indicators

15. QBS
• Each indicator is the target value for
coverage to achieve to get the QBS fee.
• Each indicator gives the points
• The indicator gives the overview about
activities what are done with the target
group in the last year
• The target value for coverage will be
change every year to based on the last
year results
• All indicators are described and available

16. The number of FB who got the QBS fee
Year
The number of
FB who got the
QBS
Proportion of all
FP
2009 355 52%
2010 281 39%
2011 398 53%
2012 412 53%
2013 434 54%
2014 447 56%
2015 471 58%
2016 494 62%
2017 543 70%

17. QBS is develpoing process
• new indicators will add cooperation with
Family Physicians Association
• new indicators base on clinical quidlines or
activities what both parties want to motivate
• Activities to help FP who don’t get the QBS
fee to achieve indicators targets
• WB group QBS evaluation approve and
develop the system

18. Thank You!