Health care services

Health care in Estonia

In Estonia, health care is divided into three levels: first contact care or family doctor care, specialized medical care and nursing care. For receiving health care, as a rule, first should be turned to the appointment of the family doctor, by whom patients are guaranteed a quick consultation, the necessary examinations and treatments, and, if necessary, referral to the next level of health care. In case of a need for emergency medical treatment, one can by themselves go to the accident and emergency medicine department or call an ambulance. The Health Insurance Fund enters into annual contracts with family physicians and medical institutions, which agree by disciplines to the extent of which amount of medical services are provided to the insured and will be funded by a particular medical institution. Each medical institution shall organize its activities (investment in equipment and material conditions, patient visits, staff costs, proper maintenance of waiting lists and compliance with treatment quality requirements) according to the legislation governing the provision of health services, the commissioning of the Health Insurance Fund and the demand of the insured for the service.
Health insurance package - a list of health care services and prices
The money received by the Health Insurance Fund - the health insurance part of the social tax - is used to pay for the medical services and health research provided to the insured on the basis of the awarded contracts.
All the various services received for the insurance are included in the so-called treatment package which is reimbursed by the Health Insurance Fund. Sometimes people mistakenly assume that health insurance will cover all costs related to medicine. Most of the health care services are reimbursed by the Health Insurance Fund in full, but the patient will also have to pay partially for some services and for some medicinal products.
The services partially or fully reimbursable for the insured include:
1. Partial or full payment for health care services to the health care institution, including:
• Going to the appointment of the doctor or the nurse (see also fees)
• Diagnostic checks
• Treatments
• Preventive activities
• Surgeries etc.
2. Enabling more affordable medicinal products for the insured, or reimbursements to pharmacies for discount medicines (see also discount drug sheet)
3. Reimbursement of medical devices - such as the blood glucose meter test strips, intraoperatively or postoperatively mounted medical equipment, etc. The exact list is on the sheet of medical devices.
4. Cash benefits to the insured person - Benefit for temporary incapacity for work, denture benefits for the elderly  etc.
5. Health promotion - such as funding for cancer prevention checks

Health insurance is characterized by two dimensions: The insurance package demonstrates the extent of the number of services and other benefits that are financed by the Health Insurance Board (list of services). The depth of the insurance package explains the extent to which services and benefits are covered by the Health Insurance Fund (how much will the Health Insurance Fund pay for the service).

For what exactly and to what extent the Health Insurance Fund pays the non-monetary benefits, is established in three legal instruments, of which the most important is the list of health services.

Health Insurance Fund and health care institutions

The budget of the Health Insurance Fund consists mainly of the health insurance segments of the social tax, which are used mostly for payment of the medical services and medicines of the insured person. The medical services of the person insured by the Health Insurance Fund are paid for by the Fund to the medical institution under contract. The prerequisite for the payment is that the service provided by the medical institutions must be part of the health insurance package (see the first paragraph).

Agreements have been signed with health care institutions all over Estonia. The total amount of the Health Insurance Fund allocated to treatment services is distributed among regional offices of the Health Insurance Fund in accordance with the number of insured persons in the service area. Distribution of the budget of specialized medical care is performed on the basis of the number of all the insured in the area, in the case of children's dental care, the number of children under 19 years of age and in the case of nursing care, the number of persons more than 65 years old in the region. On this basis, the Health Insurance Fund enters into contracts with the medical institution for the purchase of medical services.

What is the list of health care services and why is it needed?

The list of health care services contains all the medical services, procedures, the drugs necessary in the hospital and other items belonging to the health insurance package with their prices and the conditions of payment thereof. The Health Insurance Fund pays for the services on the list of health care services to the health care institution if it is provided to the person with health insurance on a medical indication.

The criteria for amending the list, and the conditions and procedures of their assessment, is established by the Government of the Republic. The list of health care services will be updated annually, according to need and the financial resources of the fund, so that a person can receive the best possible care, taking into account the evidence-based manner of the treatment, including medical efficacy and cost-effectiveness.

The Health Insurance Fund is able only to pay for those health care services, under these conditions and at the maximum price, which is set by the Government of the Republic in the Regulation of Health Care Services. The cost of the tools for the provision of the services, such as equipment, instruments, etc., are changing, and the methodologies and the treatment organization used in health care are evolving. Therefore, the costs are also changing, and financing must go along with it. Thus, the choice of health care services and their prices must be constantly updated. In order to make decisions on amendments, advance cooperation is performed with specialists and involved experts in their field, and then a broad-based analysis is performed. The list of health care services is updated in collaboration with family doctors, hospitals, and specialists in the field.

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