Private healthcare reimbursements

State subsidies for private sector services have long been a curious part of the Finnish healthcare system.

The public healthcare sector is tax-financed save for moderate user fees – but the clients of private clinics also get reimbursements from the tax-financed Social Insurance Institution (Kela). The refund is calculated based on a schedule set by the SII – there’s a fixed rate for every medical procedure – but generally amounts to some 20 % of the total costs to the consumer.

The subsidy has sustained an unending argument.

One side says that supporting the (generally better-off) clients of private clinics out of the taxpayers’ pockets is both costly and unfair and serves to deepen the healthcare gap between the rich and the poor.

Others say the reimbursement creates a big enough incentive to use private services instead of overburdening the under-resourced public healthcare system. Thus it would protect the public sector from collapse and even generate savings for the state since the clients still pay 80 % of the costs out-of-pocket.

Which side is right depends on the price elasticity of demand for private healthcare and a number of other things, but as the new government has recently decided to cut the reimbursements considerably, I’m sure we’ll find out soon enough.

(See also: Effects of the national health insurance reimbursement system on private medical services / Finnish Medical Journal 12th June 2015)

Food of the future

nightmarketCrickets @ Helsinki Night Market / The Night of the Arts.

A Summer in Psychiatry

Since the beginning of July, I’ve been working on a psychiatric ward. The experience is in so many ways unlike my previous work in primary care.

First, the pace is different. As a GP, I would see around 10 to 25 patients each day (depending on whether they came for some minor acute illness or for more extensive checkups). In this ward, I sometimes only meet 3. But I have time. Sometimes a consultation will last up to 1,5 hours, and I have no doubt they could last more. It’s far from the assembly line tempo of the rush hour ER (“state your complaint… no, just one please… ok, here’s your prescription, get outta here”). And I like it. It suits my way of working. It’s a more comprehensive take on the biopsychosocial whole.

The overall working method is different. “Multidisciplinary” is such a buzzword in medicine these days but for me, the psychatric wards are the first place where I have really been part of a multidisciplinary team and witnessed how much it can accomplish. A psychologist, a social worker and an occupational therapist (plus sometimes a physiotherapist) are all there and can help tackle problems from anxiety and depression to not having enough money for a bus trip back home.

The results of the treatment, too, are different from what I thought. I came to the psychosis ward half expecting to meet people with so grave and chronic illnesses they would be beyond any help I could possibly offer. I’m happy to find I was wrong. True, I have received patients whose schitzophrenia or drug problem has worn out their cognitive capacity and left them quite crippled and ostracized, plenty of tragic life stories. But somehow, we could help each one of them one way or the other. At least we could take out the meanest edge of the voices inside their heads or offer some consolation for longstanding feelings of shame and self-loathing. The majority return to their homes in better shape than they arrived in.

There is some existential anxiety out there that reaches to the very core of one’s soul and concerns one’s perception of reality itself. Even when there is no cure, being able to alleviate at least some of that somehow feels every bit as important as treating an aching knee or a swollen eye.

Prescribing cheap

A while ago, I received a letter from the Social Insurance Institution (the government agency responsible for the Finnish social security programs including subsidizing drug prices) that summarizes some key figures regarding my prescriptions from year 2014. (It’s the very first such letter by the way: I’ve been practicing medicine for a little more than a year now!)

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I was surprised to find that my average prescription cost was only around half of the Finnish average. Why might that be?

The most obvious explanation is that I work in primary care, not in, say, oncology or rheumatology where some useful drugs just happen to be quite expensive. But that’s unlikely to be the whole story: when compared to other non-specialized doctors my figure was still 42 % lower.

I believe one reason is that my basic toolkit of drugs includes molecules such as metformin, ibuprofen, ramipril, omeprazole, escitalopram and paracetamol – tried-and-true medications whose patents have expired. The market is flooding with “me-too drugs”: slight modifications of existing molecules that are heavily advertised and expensive but offer few benefits over the originals they are trying to replace. In these cases, going for the cheaper alternative will not hurt the patient a bit: they (and the national economy) will get the same benefit without wasting any money.

In the case of equally safe and effective medications where the more expensive one has some minor edge over the cheaper one – such as the newer oral anticoagulants which, unlike the older warfarin, do not require as extensive laboratory monitoring – I lay out the facts, and often the patient opts for the more affordable option.

Prosperity Without Growth: ”It’s capitalism, Jim. But not as we know it”

I’ve had serious doubts about the degrowth movement in the past, not because I wouldn’t sympathize with their concerns over the globe but because I used to think their views were based on intentional misunderstanding of economics.

After reading Prosperity Without Growth: Economics for a Finite Planet by Tim Jackson, I’m not so sure anymore.

Jackson, an economist himself, does not claim that economic growth is evil, on the contrary it is still very much needed for the poorest countries (I would also argue it is needed for poor populations in prosperous industrial countries).

But because of diminishing marginal utility more growth in the developed world will not increase wellbeing much; Jackson argues it may even turn against it’s purpose. When you’ve been starving, eating that first sandwich will be blissful, the second great, the third alright and the fourth will only make you fat.

What I learned in my first Economics class is that infinite growth and finite resources need not be conflicting ideas because they can be decoupled. While resources are being used ever more efficiently, Jackson arguments that a true decoupling has never taken place, nor will it in the foreseeable future.

Another reason why even the most sceptical reader should not dismiss zero-growth theories offhand is that even without any environmental or moral considerations, zero growth might be inevitable at some point due to rising prices of commodities etc. Better to be prepared?

Jackson’s final chapter offers some ideas for achieving sustainable prosperity which are easy to agree with. The more you dislike degrowth buffs, the more you should read this book. 4 out of 5.

A dead malicious move against undocumented migrants

The piece of news is one week old already but still makes my blood boil.

In the final days of the sitting parliament, MP Kari Rajamäki of the Social Democratic Party pulled a dirty trick to block a law proposal that would have given undocumented children and pregnant women access to public healthcare.

The law had been well prepared by the National Institute of Health and Welfare and backed by the social and health committee as well as nearly all MPs. In other words, it was certain to pass – if Rajamäki had not utilized a little-known loophole in the legislative process to postpone the hearing beyond the current parliament’s term, in effect cancelling it.

Whatever the encyclopedic definition of a jerk is, ”someone that deliberately sabotages the right of poor women and children to receive care” must come close. 

I didn’t know stuff like this was even possible in a Western democracy. Rajamäki has been scolded by next to everyone – including members of his own party – for his disinterest of human rights and his mockery of the democratic process. He conveniently dodges all consequences – by retiring.

Well, the law will pass the next time around. Time to elect some more responsible people onboard.

The Sacred Drunken Cow

Look at this graph and tell me retail sales don't matter for alcohol consumption.

Look at this graph and tell me retail sales don’t matter for alcohol consumption (source).


Let’s face it: The Finns are in denial about alcohol and public health. Arguments supported by data are regularly dismissed in public discussion and downvoted on internet forums: most recently in the context of the Centre Party’s suggestion that the sale of mid-strength beer be restricted to liqueur stores.

It has been estimated that this very measure would cut alcohol-related deaths by 350 a year.

When mid-strength beer arrived in Swedish and Finnish grocery stores in the 1960s, alcohol consumption and associated illness exploded. When Sweden later reversed this policy, it was a public health victory (pdf).

Unsurprisingly, the brewing industry has cried out against sale restrictions, but so have many citizens. It’s like a fundamental civil right was at stake.

The opponents’ fears include…

  • increase in total alcohol consumption should the Finns begin to visit liqueur stores more frequently (unfounded; empirical evidence says the opposite)
  • increase in imported alcohol (unlikely, since 90% of Finns live within a few kilometers of a liqueur store, but even if realized this would likely be far outweighed by the positive effects)
  • unemployment in breweries and retail trade (probably some, but again – what is a few lost jobs compared to 350 people killed a year, not to mention other costs to society and families)
  • paternalism, slippery slope, prohibition, freedom of speech, #byroslavia, #sovietfinland.

I’m not pushing for prohibition, I like mid-strength beer as much as the other guy. It’s just that I can walk an extra 100 m to get it if that is the price of a healthier nation.

Keppana Alkoon prkl!