TALLINN, 1 November 2018 – The National Audit Office found that unsolved problems in family health and specialised medicine have led to the situation where increasingly more people who generally do not need emergency care go to emergency medical departments (EMD). More than half of the people who went there in 2017 were this kind of patients. People should primarily get help from their family doctors, because this would make it possible to reduce the waiting lists at the EMD caused by overburdening as well as save money – the treatment of simple problems at the EMD is four times more expensive on average than treatment by family doctors.

The main obstacle to the normalisation of the situation is the uneven level and accessibility of family health care, long waiting lists for specialised medical care, inadequate IT solutions and the different attitudes and awareness of patients.

The number of times patients who went to the EMD in Estonia in 2017 was ca 462,000, which is 13% more than in 2010. There were 300,000 such persons, i.e. every fourth resident of Estonia. The condition of the patient was life-threatening in ca 5% of these cases.

According to the survey carried out at eight of 19 EMDs, 49% of the remainder of visits to the EMD, excl. traumas and visits by children, were because of problems where a family doctor could have helped the patient. There were fewer such cases in 2010 – 39%.

For example, last year the share of patients who visited the EMD at Northern Estonia Medical Centre with simpler health problems who could have received assistance from a family doctor was 55%.

In total, the share of patients who went to the EMD in 2017 with conditions that did not require emergency care and who should’ve received assistance from another level of health care was 57%.

The overburdening of the EMD has led to the situation where the seriousness of the patient’s condition could not be determined on time in almost one fifth of cases and in one tenth of cases, the patient did not get to see a doctor as soon as required. The condition of some of these patients was life-threatening or potentially life-threatening.

The EMD is the most expensive place for treating patients in the health system. For example, the money spent on visits made to the Northern Estonia Medical Centre and the Tartu University Hospital because of simpler health issues is approximately four times as much as the average spent on a visit to a family doctor. Appointments with specialists and the additional tests and procedures performed by them make the EMD more expensive.

The total cost of the EMD’s medical invoices in 2017 amounted to ca 153 million euros. The amount spent on treatment by family doctors in the same year was 114 million.

The audit revealed that the reasons of this situation are as follows:

The quality and accessibility of family health care is uneven. 40% of the people who went to the EMD with less serious complaints said they did this because they couldn’t get an appointment with their family doctor at the right time. 25% did not want to go to their family doctor for various reasons. Also, there are too few family doctors in Estonia who offer appointments outside working hours – only 9%. Their distribution throughout Estonia is uneven as well. For example, in 2017 there were no appointments outside working hours in almost half of Estonian counties, but also in cities like Tartu and Pärnu.

Statistics, however, indicate that approximately 60% of patients with simpler complaints go to the EMD from 8 to 18 on business days, i.e. at the time when family medicine centres are usually open and the patient could’ve gone to the family doctor instead.

The quality assessment of family medicine practices in 2017 indicated that 43% of them complied with the higher level. The remaining practices were at lower levels or had not been assessed yet. Although assessments have been carried out since 2009, approximately one-third of family health practices have never been assessed, which means that there is no information about the level of these practices.

The results of the expert analysis carried out by the Estonian Association of Emergency Medicine Specialists also indicated that the quality of family doctors is uneven – in ca one-fifth of cases, the earlier activities of the family doctors of patients who went to the EMD with back pain hypertension or infections of the lower respiratory tracts had been insufficient. For example, the family doctor had not referred the patient to a specialist, ordered the necessary tests or prescribed a medicine. However, the activities of family doctors are mostly adequate.

If a patient cannot get the help they need from the family doctor, they seek it elsewhere. The easiest and fastest alternative in the present health system is going to the EMD.

Uncovered need for treatment in specialised medical care causes long waiting lists. The financing of specialised medical care does not cover people’s need for treatment in Estonia. The total number of cases not financed in 2018 is 245,000. In the opinion of the Health Insurance Fund, these are cases where people need to see a doctor immediately, but the Health Insurance Fund does not have the money to pay for it. Another 52 million euros is needed to cover the need for medical care this year.

However, the data of Eurostat indicates how many people find that they have not been able to see a doctor at the right time due to long waiting lists – in Estonia, this perceptive indicator is the highest in Europe. Long waiting lists are one of the reasons why people go to the EMD.

The family health and specialised medical care funding system contributes to the large number of visits to the EMD. Hospitals are interested in getting as much of the money as possible under the contract and visits to the EMD are one way of achieving this. If a patient goes to the EMD with a simple health problem that could be treated by a family doctor, the hospital will still be paid on service-basis, i.e. for the visit to the medical specialist. Thus, hospitals have no financial motivation to reduce the number of visits to the EMD. However, the bigger the amounts of health insurance money spent on visits to the EMD, the smaller the amounts left for scheduled treatment, which in its turn leads to longer waiting lists.

Family health care is financed per capita. A family doctor's income does not depend on whether and how fast they admit patients with acute health problems or how often and with which health problems their patients go to the EMD. In other words, family doctors have no financial motivation to prevent the visits of their patients to the EMD, because the family doctor loses no money and saves time if the patient is treated elsewhere.

The representatives of several hospitals pointed out in the audit that there are family doctors in their catchment areas who refer patients to the EMD although the condition of the patient gives no reason for this.

This shows that the parties of the health system have no financial motivation to reduce the visits of patients with simpler health problems to the EMD.

Inadequate information systems prevent the cooperation of family doctors and the EMD in the treatment of patients. Due to the present health care administration, a family doctor is not notified when their patient goes to the EMD. A family doctor finds out about a visit to the EMD by a patient in their list only if the patient or their next of kin informs them about it. The lack of necessary information means a family doctor cannot intervene at the right time after a visit to the EMD to prescribe the subsequent treatment needed by the patient. Also, the doctor who sees the patient in the EMD cannot always obtain an overview of the tests and procedures carried out and the treatment scheme prescribed for the patient earlier, because information gets to the health information system with a delay.

Patients are not informed systematically. The behaviour of patients when visiting the EMD as well as before and after indicates that people don’t know where to go with their health problems and whether they need to go anywhere at all.

For example, some of the patients who visited the EMD with lighter problems did not know that a family doctor would've been able to help them. They also did not know that they can visit a family doctor in the case of an emergency. Traumas and intoxication excluded, 11% of the patients with other health problems had not visited a family doctor at all during the year before the EMD visit and 12% had not visited a family doctor during a year after visiting the EMD.

Thus, even after visiting the EMD, some patients don’t go their family doctors for subsequent treatment and do not follow the treatment scheme. The expert analysis prepared by the Estonian Association of Emergency Medicine Specialists indicated that the health behaviour (incl. visits of the family doctor and medical specialists, taking of medicines, going to tests) of the patients who suffered from back pain, hypertension and infections of the lower respiratory tract before they went to the EMD had been inadequate in 49% of cases. Health behaviour after visiting the EMD was inadequate in 34% of cases.

The present health care administration is such that doctors, nurses or health care institutions must explain which problems justify a visit to the EMD. This is why recommendations tend to be based on the staff and organisation of work of the specific organisation. Information should be provided systematically, so that patients would get the same message from all levels of the health system.

People without health insurance get to the EMD in poorer state of health, which makes treatment more expensive. As access to other medical care is limited for uninsured people, they often go to the EMD after their health problems have worsened. This is why treating people without health insurance is more costly. According to the Health Insurance Fund, their average medical bill for outpatient treatment in the EMD in 2017 was ca 27% (84 vs 66 euros) and the average medical bill for inpatient treatment of patients hospitalised from the EMD was ca 33% (2,395 vs 1,803) bigger than the bills of insured patients.

Auditor General Janar Holm said when commenting on the audit results:

“Treating patients in emergency medicine departments is the most expensive way of doing it in the present health system. Emergency medicine departments have basically become the places where the problems of other levels of health care are solved, but more expensively.

The solutions to enabling emergency medicine departments to operate primarily as providers of emergency care lie at other levels of health care and cannot be solved solely by giving more money. It is necessary to shorten the waiting lists of medical specialists by using e-consultations more extensively and implementing a single digital registration system; the quality of family health care should be improved by involving mentors who help family health practices at lower levels to catch up; the establishment of new health centres will make it possible to extend their opening hours, if necessary, to the evenings of working days as well as to weekends for a short time.

Raising the awareness of patients and guiding their behaviour must also be given attention. One option for this is to start offering telephone consultations to patients with simpler health problems before they go to the Emergency Medicine Department in order to give them the most suitable EMD appointment, refer them to their family doctor or give them instructions for solving the health issue at home.

However, the first precondition to the realisation of these solutions is that the Ministry of Social Affairs and the Estonian Health Insurance Fund take a stronger leading role in the development of the health care system.”

Background

• There are 19 emergency medicine departments (EMD) in Estonia, which are based by the hospitals belonging to the hospital network development plan.
• Approximately 300,000 patients made ca 462,000 visits to the EMD in 2017.
• 80% of patients are sent home after visiting the EMD and 19% are hospitalised.
• Approximately 60% of patients with simpler complaints go to the EMD from 8 to 18 on working days.

The National Audit Office assessed in the audit whether:

• the patients who go to the EMD need emergency care;
• the patients who went to the EMD received timely and necessary medical care before they went there;
• the patients were given timely and necessary subsequent therapy, if necessary, after going to the EMD.

Toomas Mattson
Communication Manager of the National Audit Office
+372 640 0777
+372 513 4900
[email protected]
[email protected]
http://www.riigikontroll.ee

• Posted: 11/1/2018 11:00 AM
• Last Update: 10/31/2018 11:59 PM
• Last Review: 10/31/2018 11:59 PM