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The MVP of the Danish Health Care System: The GP

By: Simran, Sydney, Lauren, Caroline, Alexa

Who: Mikeal Jakobson

What: A general practitioner

When: He works 40+ hours a week and 2-3 night shifts a month with enough time to be a carpenter on the side.

Where: Horsens, Denmark

How: With a positive attitude, he sees more than 30 patients per day in office, and also offers telemedicine.

What surprised us about the visit:

Mikeal focuses his practice on a sense of mutual trust with the system and the patient.

Mikeal actually likes the Danish health care system and sees it as a super efficient model.

Mikeal has a humanistic view. He was very focused on “seeing people as humans instead of boxes.”

Mikeal makes a huge impact on the general population with specialties that vary from acute care to prenatal care.

Relevance to Public Health:

Patients are more inclined to come back to him for checkups, and because of this, he can work on continuous preventive health. 

Preventive care is more organic because there is the mutual trust with the doctor.

Financial and psychological barrier with doctors visits is removed because the system is financed by taxes and so patients are redeeming a service instead of purchasing one.

This is a cost effective model and to actually see it in person is astounding. This shows us the successes of the Danish health care system.

Our Conclusions and Insights:

We were shocked by the efficiency of the system but we reflected on the point that the Danish population is a homogeneous, smaller population with a different culture that fosters trust and efficiency.

When thinking of a clinic we often think of a run down place. It has a negative connotation in America. This is not a case here, where a clinic is a place for the healthy populations.

Future Questions:

Is this a sustainable model that will be able to continue? How is burn out going to affect the Danish health care system?

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KELA

Erin, Amelia, Hannah F, Megan, Simran, Casey

Keep Everyone Learning (and Laughing!!) Always

  Walking into the KELA institute we had the assumption that a system with three different health insurance options, public, private, and occupational, would cause a lot of confusion for the Finnish citizens. However, after hearing Jenni Blomgren speak about the Finnish healthcare system, it became clear that it is more transparent than our previous conceptions. In addition to the health insurance options, KELA also provides general social welfare benefits that create a more comprehensive approach to health.

KELA provides Finnish citizens with extensive in person customer support by offering online and phone services in addition to accessible in person consultations (185 local offices). These services allow citizens to easily utilize, navigate, and understand the three healthcare sectors. Blomgren also emphasized that she and her fellow KELA employees value their customer service, and they want to help all citizens understand their services and the Finnish healthcare system.

Yet despite these accessible and universal services, the highly decentralized Finnish healthcare system does foster inequality in terms of free and quick services. The three systems clearly benefit those of higher socioeconomic status who are employed because these citizens can use the occupational healthcare system, and they can most likely afford private healthcare. The problem is that both occupational and private healthcare tend to have much shorter waiting times and easier access to specialists as compared to the public healthcare sector. We also want to consider how these differences may affect quality of care for different sectors and socioeconomic classes within the population. Though there are defined costs for hospital stays, outpatient care, etc., the high yearly ceiling costs for healthcare services (around 683 euros) make it difficult for lower income populations with higher comorbidities to navigate the system. However, no matter what social class these citizens are in, all residents at some point in their lives are customers of KELA.

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Pirita Family Health Clinic

By: Hannah K., Aisha, Caroline, Rachel, Kirsten, and Elizabeth

Given our understanding of gatekeeping in Denmark and its role in eradicating inequitable healthcare, we looked to the Estonian’s primary care system to act similarly. However, this visit left us with many questions about the true gatekeeping system of Estonia. Although Dr. Tiia Ruuva provided great insight into her own practice, our understanding of the shortcomings of the Estonian healthcare system, especially within lower socioeconomic municipalities, is left largely unexplored.

All municipalities receive the same funding regardless of the economic or health status of the population. This seemed potentially inappropriate in creating a more equitable health system, especially as Dr. Ruuva discussed the quality bonus available to doctors with more successful prevention rates. She continued to assure us that Estonian citizens are well informed on the healthcare system, but this is skewed toward her practice which is located in an area of high socioeconomic status.

Estonia is facing similar mental health challenges to those we see in Denmark and the US, such as rising numbers of anxiety and depression, especially within the younger population. Dr. Ruuva was very aware of these dangerous trends, but uncomfortably acknowledged that she was not qualified to treat these children in her general practice. However, she has no other choice due to the difficulty of getting appointments with psychiatrists.

In regards to health promotion, Dr. Ruuva highlighted the success of the men’s health campaign in Estonia as she has seen increasing numbers of men coming to her practice for primary care and check-ups. During these visits, Dr. Ruuva takes the time to also address important lifestyle behaviors, such as bringing up the issues of alcohol and obesity. In response to our questions regarding health promotion, she said, “I think overall a doctor should be an example to the patients.”

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Finnish Cancer Registry by Julia Morrison, Sophie Arzt, Claire Bacon-Brenes, Anniqa Karmali, Grace Barker, Nadine Dogbe

Our academic visit was to the Finnish Cancer Registry, which in addition to maintaining screening program databases, is also an institute for statistical and epidemiological research. We really enjoyed learning about Cervical Cancer Screening, because it allowed us to see the healthcare system in action. We learned that an effective screening program aims to reduce mortality and morbidity and attempts to find the balance between the costs and the benefits of the program.

It is impressive that Finland is able to obtain such high coverage rates (87% over the past 5 years) due to the decentralization of the system with over 300 municipalities. Despite these high coverage numbers, participation rates are declining. Our presenters postulated that this most likely due to the increased awareness of younger generations and their involvement in opportunistic screening. Though, we were surprised about the lack of access to opportunistic testing data, and curious as to how this can be improved.

It was interesting to learn about the disparities between regions, specifically, how the NW area of the country has lower vaccination rates which are most likely due to anti-vaccination sentiments. Learning about these groups exposed us to the universality of some of the issues that public health systems face and how difficult it is to educate and engage populations on such a large scale, whether it be the United States, Denmark or Finland.

Additionally, we found it interesting that HPV vaccination is only available for girls. We believe that both Finland and Denmark should be including boys in this vaccination campaign. Furthermore, we are curious as to the percentage of patients that successfully complete the three vaccinations that are advised. In comparison to Denmark, we saw that the cervical cancer database is not as comprehensive, due to the decentralization of the system. If a Finnish citizen were to choose to get screened at a private hospital or through the occupational health system, the Finnish cancer registry would not receive the testing results.

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Quinn Gonzales, Audrey Cheng, Dana Herbsman, Zoe Stein, Adena Goldberg, Haley Lipo Zovic

    At the Estonian Health Insurance Fund, Pille Banhard discussed the overall and financial makeup of Estonia’s healthcare system. The fundamental principle of “solidarity” ensures that if one is ill the government will pay. Interestingly, 96% of the Estonian population is covered by the system, yet only 49% is tax-contributing. 47% is non-tax paying but are equal to the insured in coverage. This group is comprised of women on maternity leave, students, disabled people, and children. From our perspective, we wonder if this creates a resentful divide between those who pay-in versus those who just recieve care? Additionally, the health promotion and disease prevention budget in Estonia is low. Therefore, we wonder if there are health prevention and promotion schemes organized by tax-paying citizens, to reduce their health financial burden? We learned about their advanced eHealth system, which Banhard attributed to the late separation from Russia in 199, allowing Estonia to build an advanced technological platform.

Some future challenges we see within the system include:

How might they re-work their budget in order to account for an aging population and increasingly expensive healthcare services?

Is the fact that the municipalities are all funded the same amount, regardless of patient demographic, a reflection of soviet era, ie: equality vs equity?

  The goals of the Fund are:

Ensure equal access to services/pharmaceuticals

Develop a high quality system

Shape the awareness and healthy behavior of the people

Ensure efficient use of insurance resources and sustainable development of health insurance system

Improve operation of the organization

  Although these goals help show that the fund is working to overcome their challenges financially, socially, and clinically, there is room for improvement. In the overall discussion of public health, the EHIF is pushing for a healthier population.

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Køge Emergency Department | PH A 2018

Claire, Grace, Julia, Nadine, Sophie, and Anniqa

We thought this field trip was incredibly inspiring and interactive. We spent an extra hour at the emergency department at Zealand University Hospital engaging in conversation with Dr. Kirsten Engel. Kirsten is an American M.D. and has practiced in emergency departments in both the United States and in Denmark. Kirsten’s engaging presentation was a reflection of her passion for communication between patients, doctors, and the overall system. She emphasized the important role of the general practitioners as gatekeepers within the Danish healthcare system, and how in the U.S., the patient is responsible for the management and navigation of their care.

In order to give us a better understanding of how the system works, Kirsten walked us through two different case studies and how they would progress in both nations. This exercise really emphasized the difference between patient-control in the US and system-control in Denmark. All of us were taken aback by the impact that the advice line has on the productivity and efficiency in the Danish system. This was also a great way to compare the strengths and weaknesses of the US system and the Danish system (see attached photo). We really appreciated her rational approach throughout her presentation and how she constantly challenged us to think about both sides of the argument.

From a public health perspective, we realize there are many different ways to organize a healthcare system and none are perfect. Kirsten highlighted the fact that no system is better than the other, that each is extremely specific to the dynamics of the population, and we have the ability to learn from both. Doctors and politicians need to work together to make improvements and there is value in countries learning from each other’s systems.

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Odense University Hospital, HIV Specialization Clinic

              By Adena, Audrey, Dana, Haley, Quinn, and Zoe

During our visit at the Odense University Hospital HIV Specialization Clinic, Dr. Olav Larsen and Helle Møller introduced us to HIV within the Danish health system. Similar to the United States, a strong stigma is associated with HIV. Olav and Helle shared powerful stories that were demonstrative of living with HIV, but they did not attempt to disguise patients’ identities. Although they did not share names, we were shocked by both the lack of anonymity and by how many details were given about the patients during the presentation. Due to recent budget cuts, the clinic no longer employs a social worker or psychologist, however, they can refer their patients to the HIV Foundation (an NGO).

  We were impressed by the progress the Danish health system has achieved as far as HIV treatment and transmission prevention, but we noticed several possible factors that have prevented Denmark in becoming the first country to be HIV transmission free. For example, those who are HIV-positive still face heavy stigma, PrEP (Pre-exposure prophylaxis) is not yet freely available to the general population, and there are still a large number of individuals that remain undiagnosed, this group is referred to as the “Dark Number.” Immigrant women are a vulnerable population who face language and cultural barriers. Additionally some GP’s aren’t comfortable with broaching the intersection of care regarding HIV-positive patients. Denmark may be a forerunner in HIV treatment and prevention, however, improving education and de-stigmatization are crucial for the future.

  Further questions include:

What needs to be done in order to make PrEP available to the public?

How might the cut of the social worker and psychologist impact the current and future patient population, mentally and emotionally?

How will Denmark go from 90-90-90 to 100-100-100?

What is Denmark doing to address the “Dark Number”?

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DaCHE Visit

By: Hannah F., Megan, Casey, Erin, Amelia, and Simran

After touching upon healthcare economics both in class and with DaCHE’s Troels Kristensen, it’s evident that this topic is complex. We realized that there is no clear best method of financing the healthcare system. However, one of the most interesting points from this visit is the continuing debate regarding quality of care and the 2019 negotiated reforms. What is the most efficient and effective method of healthcare delivery? Kristensen discussed the impending shift from the 2003 required 2% increase in yearly productivity to the 2019 focus on a prioritization of quality of care. This recent reform has raised further questions about the potential financial incentives to balance expenditures with health outcomes.

Since negotiations between the regions and government are annual, we fear that this small time frame does not allow for full commitment to any new changes. As Troels mentioned, “the health care system needs more resources, but does not need unthoughtful fast reforms.” The United States lacks this communication about reforms altogether, leaving no entity responsible for initiating positive change in our healthcare system. We see these negotiations between government and healthcare facilities in the Danish system as beneficial and something that the United States should do more of. Yet, we also recognize that a year to implement change may not be sufficient time or require enough commitment from the entities involved to disencourage “unthoughtful fast reforms.” Both the United States and Denmark seem to have a lot of work to do in order to increase productivity, but not prioritize to the point where quality is sacrificed.

The monetary incentives for healthcare seem clear cut at the surface; however, after further examination it is clear that it is hard to satisfy patients, medical professionals, and the multitude of other stakeholders that play a role in a functioning healthcare system.

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GP Visit at Familielægerne Horsens by Hannah K., Caroline, Elizabeth, Kirsten, Rachel, and Aisha

As American students interested in Public Health, we have focused our studies on understanding the breakdown of the Danish healthcare system. We have learned the importance of general practitioners in health systems; we are working to understand why there is a decline in the amount of general practitioners in Denmark, as well as the reason for the transition from solo to group practices. To delve into our interests, we decided to ask Holger Kjær why he strayed from the path of cardiology to become a GP and open his group practice:

Kjær: “I wanted to be my own boss, make my own decision, and have access to a spectrum of medical cases and types of patients.”

Familielægerne Horsens clinic utilizes a “shared-care”/ “working-together” model. This means that nurses and physicians work on a team to provide the most efficient and effective care to their patients. Both nurses and physicians have their own offices, comprised of their desk space and examination tools. We were shocked to see this transparent structure as we were used to seeing examination rooms separate from the nurse’s stations and doctor’s offices. While general practitioners in the Danish healthcare system are often seen as the gatekeeper to specialists and hospitals, nurses at Kjær’s practice act as gatekeepers to the physicians. The GP’s at this office provide training to experienced nurses to give them the autonomy to make medical decisions. This model fosters stronger communication and relationships between the patient and medical staff, increasing the attractiveness of a group practice. The hierarchy often present in the U.S. healthcare system is eliminated.

This visit solidified that primary care is extremely important in Danish and worldwide healthcare. Kjær ended his presentation with the powerful line, “A good healthcare system starts with primary healthcare.”

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Finnish Cancer Registry

By Emma, Katherine, Elyssa, Emily and Nicola

Visiting the Finnish Cancer Registry was different than any other visit we had done this tour. In this visit, had to apply our knowledge of general health and the health care systems in the U.S. and Finland in order to actively participate and analyze the information he gave us. The population-based screening programs were one of the main focuses, and it was really interesting to be able to compare this system to the U.S. We learned how personal identification codes and the ability to link information in the database to specific cases was essential to making the program effective. In contrast, we do not have a system like this in the US, so we therefore have no means of easily and accurately collecting and analyzing the effectiveness of health campaigns. Specifically, it was really interesting for us to learn how they prioritize screening for cervical cancer over other cancers, such as lung cancer, that have a much higher mortality rate. This part specifically relates to our class discussion about the prioritization in of health services in Denmark. With this visit, we got a deeper understanding of how different countries chose to prioritize their health care.

Further questions:

How will Finland increase the vaccination rate of HPV?

Which would be more effective in the US given the culture: screening or vaccination?

How will the restructuring (centralization) of the government affect the screening program?

How will the program change once data on the vaccination results are analyzed in the next couple years?

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Martinlaakso Health Station

The Martinlaakso Health Station is the main center of health care for Finnish citizens residing in the Vantaa municipality. This center deals mainly with older population, with 60% of the served population being 60 years or older. Similar to other developing nations, Finland is dealing with an aging population, represented by the patient statistics. While the heath stations' goal was to create a "socially sustainable society", the aging population makes that difficult. Finland especially focuses on access to care. The KELA Card is associated with permanent Finnish residency. With this card, residents can access any Public Hospital or Health Station without additional insurance. On the surface, this creates equal access which would result in equal care. However, municipalities are in charge of health stations and the allocation of resources. With over 300 municipalities, that can lead to large variation of both care and access. In terms of priotitization, Finland puts a huge emphasis on infant mortality. Their infant mortality rate is only 3.4%, one of the lowest globally. They contribute this success to the invention of Baby Boxes - a box containing infant essentials worth about 200€. This is a very comprehensive approach Health wise. It encompasses parental needs by giving parents some sort of starting point to get prepared for their child and also ensures that the baby will have at least some of their needs met. One aspect of care that we thought would be interesting to investigate further was the private sector of care and how that will result in longer wait times for people using the public system.

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 Caroline, Carrie, Catherine, and Michelle

The GP we met with in Tallinn, Tiia Ruuval, has been working in her practice for 10 years. A main discussion that stood out to us was the attitude she had toward the concept of “gatekeeping.” In Denmark, gatekeeping is heralded as one of the most effective aspects of their healthcare system. Conversely, in Estonia, Dr. Ruuval mentioned that instead of acting as a gatekeeper, she feels that family physicians have become more “problem-solvers.” With regard to the impact of Estonia’s relatively recent liberation from the Soviet Union on citizen health today, Dr. Ruuval mentioned that older patients often appreciate physicians “taking their time” to meet with them, and bring small gifts to their appointments.  Additionally, the older population prefers to see specialists immediately as opposed to the more general family physician. This contrasts sharply with the newer generation, who Dr. Ruuval said tend to be more informed about modern medicine, and are generally more demanding of their doctors. 

As for financing, family physicians like Dr. Ruuval are funded through capitation fees that are based on the ages of their patients, reflecting how demanding those patients are health-wise. Additionally, each doctor is reimbursed for testing to an amount of up to 42% of their capitation fees. This means that if a doctor provides more than the allotted 42%, they will not be reimbursed for the costs of those tests. Dr. Ruuval felt that this number was too low, particularly given that family physicians perform more duties today, as patients are seeing specialists less frequently. Finally, in addition to these insights, we observed the more culturally relevant aspects of the family practice, such as the salt cave. We chose to focus on these takeaways because they differ dramatically from the Danish gatekeeping system that we have spent the semester learning about. 

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By: Annabelle, Lexie, Alexandra, Heather, and Alexa 

Our first stop on the study tour was the Estonian Health Insurance Fund. Here, we hoped to gain a greater understanding of how the health care system has been financed, prioritized, and established since the recent shift from the Soviet Union to an independent state. The first main point we gained was that the health insurance fund is financed by employers through a social tax plan. This type of financing is different from the Danish and US’s system, making a mix of Esping- Anderson’s social democratic and conservative models.

We also learned about how they prioritize health care. The EHIF does a yearly review to see what areas need more money based on population shifts and needs. An analytics department determines these types of trends that may affect the health needs of the population.

Finally, we learned about the establishment of the Estonian health system.  It started with a 10- year experimental period where Estonia adopted healthcare models from different countries to test and see what would fit best.  Estonia developed their current health model in 2001, which is a solidarity based mandatory health insurance.  We learned that the future of this health model is maintainable for the next 15-20 years. With the aging population Estonia will need to revise their current plan to balance the budget to cover this population. We are interested in investigating how Finland is addressing this problem so we can better compare how different health plans are utilized.

In the public health sector the EHIF plays a major role in health promotion and disease prevention. This, along with the many other roles they play, creates the solidarity seen in the Estonian heath care system- where “no one is left behind.”

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By: Sarah, Ozelle, Sam, and Stephanie

The Emergency Department of Koege Hospital was a unique experience that enabled us to continue our learning of the Danish health system, as well as to compare the emergent services offered in the United States. We were introduced to the financial reimbursement of emergency rooms, patient prioritization, and the heavy work load of health professionals. Doctors are paid in a salary fashion, but unlike GPs they do not acquire the burden of buying into a practice or the additional fee for service reimbursement.  Nurses are paid hourly and have a high patient to nurse ratio. One of the hospitals most common pay cuts occur within their employment sector because of the block grant finance mechanisms. With the lack of standardization there can be approx. 50% of lost information in patient handoffs. The layout of the observation wing was modeled after Beth Israel in Boston, MA. However, for patient privacy reasons, it had to be updated with a sound proof glass barrier. From a public health perspective, the limited number of emergent services causes a problem for patient access. On average, patient wait time for an ambulance was only 15 minutes, but they can be upwards of 1 hour away from the hospital. In addition, patients are assigned to location based hospitals which are determined by population density, not distance. Although there is a GP gatekeeping system, 75-100 patients enter daily for minor injuries. This specific visit allowed us to better understand the relationship between various facets of the healthcare system from a perspective of both a clinical doctor and health care administrator. The visit was a great way to conclude our short study tour and brought real life examples to our Danish Health Care education.

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By: Caroline, Carrie, Catherine, Michelle

Walking into the practice of Michael Jacobsen, one immediately feels comfortable. The large table surrounded by chairs creates a sense of community in the waiting room. Michael himself refers to the practice as a ‘house’, and the partnership of 6 General Practitioners as a ‘family.’ This relaxed, trusting environment is reflected in numerous aspects of the Danish healthcare system, especially in GP offices.

GPs in Denmark aren’t draped in white lab coats or other official indicators of status. They form lasting relationships with patients, as they see members of the same families for many years, and patients are always assumed to be honest with their GPs. This trust carries over to patient attitudes as well. If patients see others that need more immediate attention, they’ll allow the others to be seen first. Conversely, many American patients throw fits and complain if their wait times are too long.

In terms of treatment style, GPs in Denmark consider themselves ‘specialists in everything': they know a little bit about a range of topics. As gatekeepers, GPs see patients with a wide spectrum of complaints, and it is up to them to determine any necessary next steps for continuation of care or referrals to hospitals or specialists. During weekends and evenings, there is an emergency doctor on call for issues that arise unexpectedly, yet are not serious enough to warrant visiting the Emergency Department.

We chose to focus on these points because they struck us as being very different from the American system. They seem to be cost-efficient yet effective, and we wonder why the US has not implemented a similar method of primary care. One question that we were left with is why certain services (such as adult dental care) aren’t covered under the universal healthcare system.

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By Emma, Elyssa, Emily, Kath, and Nicola

  We noticed that the staff members at the HIV Specialization Clinic at Odense University Hospital are extremely involved in individual patient care. The framework of the clinic allows for a strong, trusting relationship to be built between the healthcare staff and the patient. This is in stark contrast to the role of the General Practitioner, whose relationship with the patient is generally not as personal. For example, the patient is not obligated to inform their GP of their HIV diagnosis, which could be related to the less personal relationship between GP and patient.

  Furthermore, this could be related to the stigma surrounding STIs, especially HIV. This makes us wonder why HIV specifically has a more severe stigma than other STIs. Both Helle and Isik agree that this stigma poses the biggest challenge to medication compliance for individuals with HIV. This is especially relevant from a public health perspective, for to improve compliance, one must address the root of the problem, which in this case is most often the stigma around HIV.

  Another challenge is the cost of medication, which can dictate patient treatment. With Denmark’s taxed-based healthcare system, the type of medication for the individual is determined by cost. This can result in the prioritization of budget over individual patient needs. For example, last year, to reduce costs, the standard treatment was increased from one combination pill to three separate pills. Increasing the number of pills can reduce compliance, so the prioritization of cost over individual patient likely had a negative effect on HIV treatment. This brings us back to the issue of stigma related to patient compliance.

Further questions:

What is being done in Denmark to reduce stigma surrounding HIV?

Does labeling the clinic as an “HIV Clinic” reinforce the stigma surrounding HIV?

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Presentation at the Regional Health Administration of the Region Sjælland