Unhealthy health costs

Unhealthy health costs – or why the health insurance-based medicine reimbursement system must be reformed

We would all prefer to stay in good health and make ends meet. The Finnish social security system and the Social Insurance Institution Kela will pitch in to ensure a decent life even when people face ill health or incapacity to work. However, the health insurance system underpinning the medicine reimbursements requires a reshuffle, especially as the chronically ill are concerned.

Healthy habits and good genetics help many people to stay in good condition throughout their lives. But not everybody is so fortunate. Faced with a disease, people seek medical care, mostly at the closest public healthcare facilities. Many go to a private doctor. If things get serious, they might need to be hospitalised.

To cope in the everyday and to fight the disease, their overall therapy will often also include pharmacotherapies. The doctor looks for the suitable medication and the other healthcare professionals ensure that the medicine user knows how to take them in the right manner.

This may lead to a positive treatment outcome, with the recovered patient back to work in good health. But sometimes the disease turns out to be permanent and chronic.

A chronic disease may impair the quality of life even if the suitable medication has been identified. Kela may contribute to rehabilitation. If the disease causes permanent incapacity to work, the next step is to make pension arrangements.

Pharmaceuticals are eligible for reimbursements from Kela if the medicine has been prescribed by a doctor and it is included in the reimbursement system. A chronically ill patient will receive higher reimbursements if

  • the particular condition is classified in the group of diseases with a higher reimbursement rate
  • the patient faces a sufficiently severe form of the disease
  • the prescribing doctor has the correct specialisation.

If these criteria are not met, the patient will pay for the medicines either in full or for the most part.

Finnish health insurance system is outdated

The current medicines reimbursement system included in the health insurance dates back to the 1960s. When introduced, the system was something new and progressive, promoting public health. Its aim was to provide everybody with equal access to good pharmacotherapies, irrespective of their individual living standards.

At the beginning, the majority of the reimbursements were paid for acute diseases. Over the decades, the situation has changed: today the bulk of the reimbursements go to the treatment of chronic diseases.

The system is still based on the early principles:

  • The diseases are classified in groups with higher or lower reimbursement rates.
  • The patients are classified as sufficiently or insufficiently ill.
  • The medicines are classified as universally or limitedly reimbursable.

Despite partial patchwork-like reforms, the medicines reimbursement system has not kept up with the developments in pharmacotherapies.

The parties paying for and benefiting from the reimbursements are sometimes the same, other times different. The Kela reimbursements for medicines are paid by two distinct parties.  The State pays half of the reimbursement through tax money while the ordinary taxpayers cover the other half through their health insurance premiums.

The party receiving the reimbursements would prefer to pay as little for the medicines as possible while the party picking up the tab would like to make each patient pay as much as possible. Trying to interfere with this delicate equilibrium has always been a great political hazard.

Towards a new medicines reimbursement system

As the old and outdated medicines reimbursement system is now under reform, certain clear improvements become mandatory.

  • Carefully studied comprehensiveness would be important for the promotion of public health.
  • The system should be modern and updated to keep up with pharmaceutical developments.  The system was very good when it was created but it has been difficult for the current system to adapt to the development and changes of pharmacotherapies.
  • Simplicity, equality and fairness would enhance the citizens’ legal protection, thereby also decreasing Kela's work load. A multi-tier system built up over different eras is too hard to manage.  Classifying diseases and people within the system evokes a feeling of unfairness and arbitrariness.  The chronically ill should not be punished for their diseases. The new system should promote equality, treating all diseases and people with the same standards.
  • Moderate cost of the system use could be attained by making the system practices less complicated, cutting the red tape and unnecessary costs. The reformed reimbursements system must also meet savings objectives.
  • Predictability is equally important to the recipients of reimbursements and to those who pay for the system.  It should not be possible for anyone to be suddenly left without reimbursements for reasons such as the State being short of money.
  • Regulating without interfering with the whole system would be important from the government point of view. It should be possible to adjust to the fluctuations in the public economy without any legislative amendments.
  • The system should encourage people to opt for healthy living habits, assuming the responsibility for their own health.
  • The insurance nature of the system should be increased so that modest costs are paid by the patient and the reimbursements are targeted at major expenses. This would allow for the reimbursements to be allocated to those with the biggest need for medicines.