Healthcare | Pensioners cheaper for a private doctor? The government is looking for a new model for Kela compensation

When the government is renewing Kela reimbursements for doctor's visits, what would be the best model in terms of Finns' health?

The Ministry of Social Affairs and Health is currently planning a new Kela compensation model, which the government wants to enter into force at the beginning of next year. Kela's medical reimbursements include, for example, reimbursements for private doctor's fees and private dental care, which cover part of the customer's bill.

Kela compensations have been cut in recent years, but the current right-wing government took a different direction.

Kela compensations were already increased for this year, for which 65 million euros will be used. This year, we are still going with the old model, where Kela reimburses a certain percentage of the costs of, for example, private general and specialist doctor visits.

The future reimbursement model is of great interest to health care providers: for example, Hyvinvointila Hali, representing the private health sector, suggests that the main target of the reform should be pensioners, in order to reduce the pressure on public health care.

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The compensation model should be agreed upon around May.

Government agreed in the budget rush that around 134 million euros per year will be allocated to the new model for the years 2025–2027. Of this, the state's financial contribution is approximately EUR 90 million annually.

According to the government program, increasing Kela compensations is intended to break up treatment queues in public primary healthcare. The opposition has criticized the allocation of money to private doctor's visits and preferred that the additional money should have been given to welfare areas.

The ministry has not been very enthusiastic about the experiments proposed by Hali and the Medical Association, in which the model would not initially apply to the entire population. It would be difficult for the government to justify why the dismantling of care queues should not be done throughout the country for all citizens.

HS is told that the Ministry of Social Affairs and Health is currently calculating the prices of different options. Among other things, the pressure comes from the fact that rehabilitation, i.e. mainly physiotherapy, would like to be covered by compensation.

There has also been discussion about what to do with some specialist medical services, such as gynecologists and ophthalmologists. Private doctors now play a big role in them.

Due to the budget schedule of the Parliament, the government should agree on the compensation model around May, so that the government proposal can be written in good time before autumn.

The Ministry of Social Affairs and Health has even calculated that Kela compensations would be discontinued altogether, after all, their importance to customers has been decreasing all the time due to cuts in compensations by several different governments. Savings for the state would be 40–47 million euros per year.

HS reviews the proposals presented by different parties.

The model presented by Kela

Coil presented his draft in the government negotiations, where the customer's deductible, i.e. the customer fee paid by him, would be the same, he went to seek the services of a general practitioner from private or public health care.

CEO of Kela Outi Antila says that it is not a model run by Kela, but that it worked at the request of government negotiators. The option Antila calls the “raw version” describes what could be possible.

This is how it would work: Kela would pay the Kela compensation for a private general practitioner visit, after which the customer would have to pay the same amount as the visit to the health center costs.

Now, the one-time payment at the health center for those over 18 is a maximum of 23 euros.

The pricing of healthcare companies would be regulated by a per-visit price ceiling. It could mean, for example, that no more than 80 euros should be charged for a visit to a general practitioner. There would also be an annual ceiling for the customer, how much the service of a private general practitioner could be used, for example 200 euros per year.

Kela's option would concern general practitioner visits, not specialist visits.

According to Outi Antila, the compensation model should be integrated, i.e. coordinated with public healthcare.

“The purpose is to somehow get people out of the public primary health care queue, for example those who need treatment for a single, acute problem. Then the public would have more resources and time for those in need of a continuous care relationship,” says Antila.

“And if there are no queues in primary health care, it will be seen on the public side as a reduction in the need for emergency medical care. Now it seems to be the case that even very minor ailments have to be referred to the emergency room.”

Hali pensioner model

Welfare sector Hali presents an experiment in which Kela compensations would be allocated to pensioners. Kela reimbursements for dental care and mental health services would remain available to all citizens.

Hali's rationale is that the number of people over 65 will grow rapidly in the coming years. As a rule, insurance companies no longer sell them health insurance because of their age, and retirement drops them from occupational health coverage.

“For them, the use of private services has not grown at the same rate as the age group is growing, and it will burden the public sector more and more in the next few years,” says the manager Hanna-Maija Kause Shake.

Hali has found out that in 2022 people over 65 had 1.56 million visits to health centers, which was about 41 percent of the visits of all ages.

Hali would like an experiment where people over the age of 65 could visit a doctor, for example, three times a year, and the reimbursements would also cover laboratory and imaging services related to the visits. Visits could also be to a specialist.

There would be no ceiling price in the model, but for example a ceiling allowance of 150 euros per visit. The part that exceeds that would be paid by the pensioner himself. You could receive compensation for, for example, three doctor's visits per year, but not unlimited.

The medical association's own doctor model

Medical Association has proposed for consideration a private doctor model, which Kela would initially organize as an experiment and regionally. At the same time, the welfare regions could use their own funding to conduct in-house doctor experiments in order to obtain a basis for comparison.

The medical association proposes capitation compensation, which means that the public funder would pay a private company compensation for the patient's treatment. The compensation would be determined according to the patient's need for treatment, which would be calculated on the basis of, among other things, age and illness: the company would receive less compensation for the treatment of healthier patients, and more compensation for the treatment of sicker patients.

The patient would choose a private doctor to treat him for at least a year. He could be charged a visit fee under the model of the Medical Association, which would not exceed the level of the health center fee.

“First of all, there is the idea that it would not only be about responding to demand and compensating services, but about the continuity of treatment. Capitation would bind the patient to the patient's own doctor by contract,” says the director of the policy department of the Medical Association Jukka Mattila.