Martti Kekomäki: Pursuing care integration in Finland

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Martti Kekomäki shares lessons from Finland on creating an integrated health and social care system.

This presentation was recorded at our conference on Mainstreaming primary and acute care systems and multispecialty community providers on 21 March 2017.

Transcript

We have the primary care systems we call them health centres. They are all owned and financed and managed by communes and then we have the secondary care which is delivered by twenty central hospitals, again, owned and financed by counties.  Then the tertiary care is delivered by five university hospitals.  Every Finn has a unique personal identification code which covers everything from taxation to court, to healthcare, to social welfare.  I can trace all the results, for instance, in aortic surgery, from fifty years.  It also enables us to bundle cost over time, so that we know what it takes to treat bronchial asthma in Finland at the individual level.  Naturally, it is also risk analysis can be done, so that we can re-stratify the patients and we can see that there are people with a welfare risk, which is down to 100 euros per year and then another group where the average cost is more than 100,000 per year. 

Also, we have a health portal, which is created by Finnish medical society, Duodecim, which gives updated information from all the care possibilities. Fifty million visits on that site per year.  The same information is dealt with in health library, which is available to all Finns over the internet.  So it means also, that it reduces the information asymmetry between patient and the health physician.  When the patient comes to see or contact over the internet, the physician, they already speak about the same level.  We use digitalised lifelong medical records, so it is more than 98 % digital already today.  So the same information flows forth and back with a primary health care and the hospitals.  Practically all social care is also administered, financed and also quite often delivered by the commune municipalities so again they are under the same hub.  All manforce is salaried, no other contract, no self-paying patients in any public hospitals.  I think that is also something which makes the managing of this kind of business easier.

Now we jump over to the problems. Inequity is one of the big problems in Finnish health care.  One is naturally, cost escalation.  It is still clearly more rapid than the growth of gross domestic production.  We have several overlapping services.  We speak about tellers, silos, repeated encounters, double examinations in a country where these all could be avoided and the services also are fragmented.  The idea that we defined health as an ability to adapt and self-manage as you have taught us Finns to think.  I think it is a very important thing.  We are working under one budget and that is set according to the estimated needs of the target population and we are trying to balance the margin of cost effectiveness across all active care and here are the asthma programmes.  This is really a sample of integrated care dating back thirty years as you see.  And what is here, very specific, is that this is an economic chart which also shows that the productivity losses can be taken into account and this green area shows you what is then replacing, what is the success story, this is medication from 87, the number of asthma patients has tripled.  The costs have not tripled and you see also how little hospitalisation costs this small blue area here.  It used to be high but now it is very rare to see any single patient in hospital due to bronchial asthma.  That was total cost at the national level and these are the individual costs at the patient level.  And again we see that the direct costs of medication, mostly from medication, are here but the productivity loss, which means sick leaves, early retirement because of disease etc. is down.  They are still in the workforce and I think that is a beautiful picture about what can be achieved by judicious integration of care. 

But how was this done? We had to target on prevention.  Ban smoking, take antigen environment into account.  The second thing is that we had to reach early diagnosis and then start effective medical therapy.  Educate, shift responsibility smoothly between professional groups, deploy virtual health examination where the doctor is able to see any single patient with wrong or deficient medication.  And that care process is to local factors.  I think it is very important that all these kinds of improvement is done on a local level, not from the governmental level.  Mobilise lay interest groups for your support.  They have tremendous power and they are willing to help you keep track over time, prevent sliding back.  If you get something done, keep it there.  Do not let it slip back and also be proud, be loud.  If you get something okay, come over to England and be proud about that. 

I end this presentation showing that Finland is really best value for money but I do not even show where United Kingdom is. And then my concluding words are that I think that integration means commitment to work together over years and decades.  Integration is the main stream and manage competition, provide marginal aid in selected situations but only in selective situations and we will see this kind of development putting together all the post industrial countries because we are all running out of money and this is not a strategy.  This is a very deep culture of change.

Thank you.

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