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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

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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)

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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

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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)

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5 The most important current monopolies pediatric cardiac surgery solid organ transplantations certain rare neoplasms

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6 Government money norms and rules monitoring municipalities hospitals health center (primary care) university hospitals research, education

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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

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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

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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

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10 Changes with opposing directions: 1c. centralization increasing the size of PHC institutions reducing the number of PHC emergency units (several examples)

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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)

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12 Changes with opposing directions: 2b. decentralization forming hospital-owned corporations (capital management, laundry) outsourcing of some services (parts of ICT)

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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

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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

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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

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16 Increasing the size of risk pools municipalities risk hospitals, public & private pool capitation by risk profile, benefit package and historical use service flow

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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)

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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

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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

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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)

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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

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22 Quality and costs of Finnish ICUs 1998 and 2001

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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

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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)

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26 HRQoL of back pain patients before and after a neurosurgical intervention

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28 15D-profiles in cataract patients before (green) and after (red) the operation as compared with age-adjusted normal population (blue)

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29 Health related quality of life in patients with esophageal cancer

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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

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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?

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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...