Liina-Kaisa Tynkkynen

Purchaser–provider splits in health care—The case of Finland

The purchaser-provider split (PPS) is a service delivery model in which third-party payers are kept organizationally separate from service providers. The operations of the providers are managed by contracts. One of the main aims of PPS is to create competition between providers. Competition and other incentive structures built into the contractual relationship are believed to lead to improvements in service delivery, such as improved cost containment, greater efficiency, organizational flexibility, better quality and improved responsiveness of services to patient needs. PPS was launched in Finland in the early 1990s but was not widely implemented until the early 2000s. Compared to other countries with PPS the development and implementation of PPS in Finland has been unusual. Firstly, purchasing is implemented at the level of municipalities, which means that the size of the Finnish purchasers is extremely small. Elsewhere purchasing is mostly implemented at the regional or national levels. Secondly, PPS is also applied to primary health care and A&E services while in other countries the services mainly include specialized health care and residential care for the elderly. Thirdly, PPS in health and social services is not regulated by any specific legislation, regulative mechanisms or guidelines. Instead it is regulated within the same framework as public procurement in general.

Framing the decision to contract out elderly care and primary health care services - perspectives of local level politicians and civil servants in Finland.

BackgroundIn the literature there are only few empirical studies that analyse the decision makers’ reasoning to contract out health care and social services to private sector. However, the decisions on the delivery patterns of health care and social services are considered to be of great importance as they have a potential to influence citizens’ access to services and even affect their health. This study contributes to filling this cap by exploring the frames used by Finnish local authorities as they talk about contracting out of primary health care and elderly care services. Contracting with the private sector has gained increasing popularity, in Finland, during the past decade, as a practise of organising health care and social services.MethodsInterview data drawn from six municipalities through thematic group interviews were used. The data were analysed applying frame analysis in order to reveal the underlying reasoning for the decisions.ResultsFive argumentation frames were found: Rational reasoning; Pragmatic realism; Promoting diversity among providers; Good for the municipality; Good for the local people. The interviewees saw contracting with the private sector mostly as a means to improve the performance of public providers, to improve service quality and efficiency and to boost the local economy. The decisions to contract out were mainly argued through the good for the municipal administration, political and ideological commitments, available resources and existing institutions.ConclusionsThis study suggests that the policy makers use a number of grounds to justify their decisions on contracting out. Most of the arguments were related to the benefits of the municipality rather than on what is best for the local people. The citizens were offered the role of active consumers who are willing to purchase services also out-of-pocket. This development has a potential to endanger the affordability of the services and lead to undermining some of the traditional principles of the Nordic welfare state.

Integrating public and private home care services: the Kotitori model in Tampere, Finland

Purpose – This case study aims to introduce a novel home care service integrator model called “Kotitori”. In the model the City contracts with a private provider, which, in turn, works with public, private, and third sector providers in order to meet the customer needs in a personalised way.Design/methodology/approach – The case study draws from key policy documents and stakeholder interviews.Findings – The study introduces a unique form of public‐private partnership in Finland, and describes the basic elements of Kotitori, the development process of the model, and the models distinctive features compared to more traditional ways of home care service delivery.Research limitations/implications – The Kotitori model is still in its early stages of implementation and reliable data on performance are limited.Practical implications – The transferability potential of the Kotitori model is good both nationally and internationally. The model is potentially beneficial for countries with an interest in developing i...

An analysis of ophthalmology services in Finland - has the time come for a Public-Private Partnership?

BackgroundWe studied the prerequisites for Public-Private Partnership (PPP) in the context of the Finnish health care system and more specifically in the field of ophthalmology. PPP can be defined as a more or less permanent cooperation between public and private actors, through which the joint products or services are developed and in which the risks, costs and profits are shared.The Finnish eye care services system is heterogeneous with several different providers and can be regarded as sub-optimal in terms of overall resource use. What is more, the public sector is suffering from a shortage of ophthalmologists, which further decreases its possibilities to meet the present needs. As ophthalmology has traditionally been a medical specialty with a substantial private sector involvement in service provision, PPP could be a feasible policy to be used in the field. We thus ask the following research question: Is there, and to what extent, an open window of opportunity for PPP?MethodsIn addition to the previously published literature, the research data consisted of 17 thematic interviews with public and private experts in the field of ophthalmology. The analysis was conducted in two stages. First, a literature-based content analysis was used to explore the prerequisites for PPP. Second, Kingdons (1995) multiple streams theory was used to study the opening of the window of opportunity for PPP.ResultsPublic and private parties reported similar problems in the current situation but defined them differently. Also, there is no consensus on policy alternatives. Public opinion seems to be somewhat uncertain as to the attitudes towards private service providers. The analysis thus showed that although there are prerequisites for PPP, the time has not yet come for a Public-Private Partnership.ConclusionShould the window open fully, the emergence of policy entrepreneurs and an opportunity for a win-win situation between public and private organizations are required.

What patients think about choice in healthcare? A study on primary care services in Finland

Background: The ongoing Finnish health and social service reform will expand choice by opening the market for competition between public and private service providers. This study examined the attitudes of primary care patients towards choice and which patient-related factors are associated with these attitudes. Methods: A sample of attenders during one week in health centres of 12 big cities and municipal consortiums (including seven outsourced local units) and in primary care units of one private company providing outsourced services for municipalities (aged 18−95, n=8128) was used. The questionnaire included questions on choice-related attitudes, sociodemographic factors, health status, use of health services and patient satisfaction. Results: Of the responders, 77% regarded choice to be important, 49% perceived genuine opportunities to make choices and 35% were satisfied with the choice-relevant information. Higher age, low education, having a chronic illness, frequent use of services, having a personal physician and being satisfied with the physician and with waiting times were related to assigning more importance on choice. Younger patients, those with higher education as well as those with chronic illness regarded their opportunities of choosing the service provider and availability of choice-relevant information poorer. Conclusions: The Finnish primary care patients value choice, but they are critical of the availability of choice-relevant information. Choices of patients with complex health care needs should be supported by developing integrated care alternatives and by increasing the availability of information on existing care alternatives to meet their needs.

Development of voluntary private health insurance in Nordic countries – An exploratory study on country-specific contextual factors

The Nordic countries are healthcare systems with tax-based financing and ambitions for universal access to comprehensive services. This implies that distribution of healthcare resources should be based on individual needs, not on the ability to pay. Despite this ideological orientation, significant expansion in voluntary private health insurance (VPHI) contracts has occurred in recent decades. The development and role of VPHIs are different across the Nordic countries. Complementary VPHI plays a significant role in Denmark and in Finland. Supplementary VPHI is prominent in Norway and Sweden. The aim of this paper is to explore drivers behind the developments of the VPHI markets in the Nordic countries. We analyze the developments in terms of the following aspects: the performance of the statutory system (real or perceived), lack of coverage in certain areas of healthcare, governmental interventions or inability to reform the system, policy trends and the general socio-cultural environment, and policy responses to voting behavior or lobbying by certain interest groups. It seems that the early developments in VPHI markets have been an answer to the gaps in the national health systems created by institutional contexts, political decisions, and cultural interpretations on the functioning of the system. However, once the market is created it introduces new dynamics that have less to do with gaps and inflexibilities and more with cultural factors.

Comparing public and private providers: a scoping review of hospital services in Europe

BackgroundWhat is common to many healthcare systems is a discussion about the optimal balance between public and private provision. This paper provides a scoping review of research comparing the performance of public and private hospitals in Europe. The purpose is to summarize and compare research findings and to generate questions for further studies.MethodsThe review was based on a methodological approach inspired by the British EPPI-Centre’s methodology. This review was broader than review methodologies used by Cochrane and Campbell and included a wider range of methodological designs. The literature search was performed using PubMed, EconLit and Web of Science databases. The search was limited to papers published from 2006 to 2016. The initial searches resulted in 480 studies. The final sample was 24 papers. Of those, 17 discussed economic effects, and seven studies addressed quality.ResultsOur review of the 17 studies representing more than 5500 hospitals across Europe showed that public hospitals are most frequently reported as having the best economic performance compared to private not-for-profit (PNFP) and private for-profit (PFP) hospitals. PNFP hospitals are second, while PFP hospitals are least frequently reported as superior. However, a sizeable number of studies did not find significant differences. In terms of quality, the results are mixed, and it is not possible to draw clear conclusions about the superiority of an ownership type. A few studies analyzed patient selection. They indicated that public hospitals tend to treat patients who are slightly older and have lower socioeconomic status, riskier lifestyles and higher levels of co-morbidity and complications than patients treated in private hospitals.ConclusionsThe paper points to shortcomings in the available studies and argues that future studies are needed to investigate the relationship between contextual circumstances and performance. A big weakness in many studies addressing economic effects is the failure to control for quality and other operational dimensions, which may have influenced the results. This weakness should also be addressed in future comparative studies.

Professionals’ views on integrated care

Purpose Integrated care policies have been at the heart of recent health reforms in many European countries. The purpose of this paper is to study the integration from the perspective of health care personnel working in primary health care clinics. Design/methodology/approach The study employs data from interviews collected in a research project examining patient choice and integrated care in primary health care clinics in Finland. The interviews were conducted in five cities in Southern Finland in 17 primary health care clinics in Autumn 2014. Among the interviewees there were both doctors (n=32) and nurses (n=31). Findings The typical problems hindering integration were, according to the workers, poor communication and insufficient information exchange between professionals, unclear definition of responsibilities between professionals, and lacking contacts and information exchange between health and social care professionals. To secure availability and continuity of care, doctors and nurses did extra work and exceeded their duties or invented ad hoc solutions to solve the problem at hand. According to professionals, patients were forced to take an active role as coordinator of their own care when responsibilities were not clearly defined between professionals. Originality/value This paper highlights that successful integration requires taking into account the requirements of the day-to-day work of health care clinics, and clarifying what facilitates and what hinders practical collaboration between different actors in health care and between health care and other service providers.

Kotitori : Integroitu palveluohjausmalli yksityisen ja julkisen rajalla

Sosiaali- ja terveyspalveluiden kentalta on mahdollista tunnistaa entista enemman toimijoita ja palveluita, joihin perinteiset yksityisen tai julkisen maaritelmat eivat enaa sovi. Yksi esimerkki taman kaltaisesta palvelusta on Tampereella vuonna 2009 aloittanut vanhojen ihmisten kotihoidon palveluohjauksesta ja palveluintegraatiosta vastaava Kotitori. Tutkimuskysymyksemme on, millainen palveluintegraation ja -ohjauksen muoto Kotitori on? Erityisesti kysymme, mita tavoitteita Kotitorin perustamiseen liitettiin, seka miten julkisen ja yksityisten toimijoiden tehtavat ja niiden valiset suhteet maarittyvat Kotitorin toiminnassa. Vastaamme tutkimuskysymyksiin analysoimalla Kotitorin perustamisasiakirjoja ja palvelun perustamisessa ja aloittamisessa keskeisesti vaikuttaneiden toimijoiden haastatteluita. Kotitorin toiminnassa julkisen ja yksityisen palvelun rajat ja tehtavat maaritellaan uudelleen. Se edustaa uudentyyppista julkisrahoitteista palvelua, jossa yksityisen ja julkisen rajat sekoittuvat. Kotitori: Service integrator and case management model in between the public and private sectors Kotitori service integrator is a publicly funded, but privately produced service in the field of eldercare services. It is responsible for case management and service integration of homecare services for the elderly. It started in 2009 in the city of Tampere in Finland. It aims to combine the resources of public and private sectors to better meet the needs of elderly service users. We study in this article, what kind of service integration and case management service Kotitori is. Firstly, we ask, what goals were included in the foundation of the service integrator model. Secondly, how are the tasks and relations between public and private actors defined in Kotitori service model? The research data consists of interviews and municipal documents concerning the foundation of Kotitori service integrator model. We conclude that Kotitori represents a novel service integrator and case management service, in which the tasks and relations between public and private sectors are redefined.