Introduction Chat-based digital clinics have become an increasingly important gateway to primary healthcare in many countries. This exploratory study describes the socio-demographic characteristics of digital clinic users, examines patterns of digital clinic use among potentially vulnerable population groups, and compares the medical reasons for chat-based digital clinic contacts with those of traditional primary care.Material and methods We conducted an observational register-based study using nationwide data covering digital and traditional contacts to public and private primary care clinics in Finland from January 2022 to February 2025. Using a rich linked dataset, we examined several potentially vulnerable socioeconomic subgroups, including individuals aged 80 and above, those with multimorbidity, the unemployed, and members of the lowest income quintile. The study population comprised 1,599,588 individuals residing in eight wellbeing services counties in Finland.Results Public digital clinic users appeared to be younger, more often women, and more often live in urban areas, and have a lower prevalence of chronic illnesses compared with users of traditional public primary care. Potentially vulnerable patient groups also used digital services, although they used traditional services more. Medical reasons for digital clinic contacts were often relatively simple, but individuals with chronic illnesses also used digital services to address their care needs.Discussion We observed differences in the characteristics of users of digital and traditional primary healthcare services. We generated hypotheses for future research on equity in digital healthcare access. Further research is needed to evaluate whether improving access to digital services for vulnerable groups could support health equity.

Postponements of non-acute care during the COVID-19 pandemic commonly raised concerns about harmful health consequences and increased healthcare costs, particularly among older individuals. Using nationwide register data from Finland, we employ a regression discontinuity design to examine the effect of an age-specific stay-at-home recommendation on healthcare utilization during the first wave of the pandemic. We find that the recommendation reduced non-acute visits, such as dental care, physiotherapy, and specialized care visits, but had no effect on acute care use, including emergency department visits or inpatient stays. The reductions in dental care use were partly compensated for after the lockdown was lifted, but not in other non-acute services. Additionally, we find indicative evidence of a slight increase in mortality during the three-months post-period after the lockdown. Our findings suggest that a Scandinavian-type social distancing recommendation targeting the elderly may reduce non-acute healthcare use in the short term, thereby temporarily alleviating pressure on healthcare resources during a pandemic. However, the absence of rebound in some non-acute services highlight potential unmet needs, which may imply longer-term risks of functional decline, preventable hospitalizations, and associated healthcare costs. These findings point to the importance of policies that ensure continued access to essential non-acute care for older populations.

We examine the heterogeneous effects of 14-21 euro copayments on primary care general practitioners (GPs) visits in Finland. Our study focuses on a triage-based appointment system in public primary care. Using an age-based regression discontinuity (RD) design and leveraging variation across Finnish municipalities in whether the copayment is charged, we analyze the effects at the 18th birthday, when previously exempted adolescents become subject to copayments. Using nationwide administrative data from 2011 to 2019, we find that GP visits decrease in the copayment municipalities by 4-5 %. The reductions are largest for the bottom 20 % of the equivalized family disposable income distribution: their GP use decreases by 0.08-0.10 annualized visits (7-10 %). Unexpectedly, the effects are also larger than average (albeit rather temporary) for the top 50 %, showing reductions of 6-8 %. Compared to earlier studies focusing on moderate copayments and different populations, our effect estimates are smaller, and the heterogeneity by income level is weaker.

Emerging strands of research have examined the family spillover effects of health shocks, usually focusing on labour market outcomes. However, the results have been inconclusive and there is only little evidence on the longer term consequences of health shocks or the mechanisms behind the spillover effects. We analyse the short- and long-term effects of cancer on the healthy spouse's labour supply and mental health by gender and relative income status within the couple (i.e., the breadwinner type). We use full population register data on all cancer patients and their cohabiting partners in Finland over the period 1995-2019. Our identification strategy is based on the quasi-random variation in the timing of the cancer diagnosis and a dynamic difference-in-differences approach. We find two main results. First, cancer increases female spouses' employment. This result is consistent with the added worker effect, although we find the magnitude of the increase in annual earnings to be negligible. By contrast, among male spouses, earnings decrease as a consequence of a spouse's cancer. Second, among women, there is heterogeneity in the effects in terms of the breadwinner status, which is especially notable in the long-term. The results show that the added worker effect is visible only among secondary earners and the effect seems to hold only when the cancer patient dies. Secondary earner women also suffer more from psychiatric symptoms during bereavement. Consequently, we argue that the breadwinner status before the health shock is a neglected factor influencing the effects of health shocks in families, and that family-level specialisation between spouses alters substantially over time in response to a health shock.

Nurses are increasingly providing primary care, yet the literature on cost-sharing has paid little attention to nurse visits. We employ a staggered difference-in-differences design to examine the effects of adopting a 10-euro copayment for nurse visits on the use of public primary care among Finnish adults. We find that the copayment reduced nurse visits by 9%-10% during a one-year follow-up. There is heterogeneity by income in absolute terms, but not in relative terms. The spillover effects on general practitioner (GP) use are negative but small, with varying statistical significance. We also analyze the subsequent nationwide abolition of the copayment. However, we refrain from drawing causal conclusions from this due to the lack of credibility in the parallel trends assumption. Overall, our analysis suggests that moderate copayments can create a greater barrier to access for low-income individuals. We also provide an example of using a pre-analysis plan for retrospective observational data.

Insurance coverage increases health care consumption, but less is known whether moderate copayments affect adults’ primary care utilization in a system characterized by gatekeeping. We analyze whether abolishing a 14-euro copayment for visits to general practitioners (GP) in Helsinki, the capital of Finland, increased the number of GP visits among adults and especially among low-income individuals. Using a difference-in-differences (DD) design and combining several administrative registers from 2011 to 2014, we find that the abolition is associated with only a small increase in GP visits (+0.04 visits annually, or +4.4 %, for all adults). The increase is driven by low-income adults (+0.06 visits, or +4.5 %, at the bottom 40 %). Although the point estimates are rather robustly positive, the conclusions regarding the statistical significance are sensitive to how we account for clustering in a setting characterized by only one treated cluster and a finite number of comparison clusters.

Abstract Objectives The aim was to analyse the costs and duration of orthodontic-surgical treatment with mandibular advancement in the public health care sector in Finland. Materials The study was conducted as a retrospective registry study in a public district hospital on all nonsyndromic patients that were ethnic Finns and treated with full fixed appliances and mandibular advancement surgery in 2016–2020. Results The mean treatment duration of the included 45 patients was 28.1 months, including 18.9 months pre and 9.2 months postoperative orthodontics. The median number of visits was 27, including 17 visits before and 9 visits after surgery. The mean total treatment time was 14.5 h. The mean total direct costs per course of treatment were 7574 € to the municipality and 947 € to the patient. The costs positively correlated with the duration of the treatment (rho = 0.71, P = .000), but were not associated to gender or age of patient. The mean surgery time was 78 minutes, and significantly less with an experienced surgeon (P = .002). It was calculated that the mean minimum treatment costs would be 45% of the present total, achievable with a patient with optimum dental arches at the start of treatment. Limitations The major limitation of the study is the relatively small number of study subjects. Conclusion A 55% share of the costs is influenced by case- and operator-dependent factors. This indicates that the complexity and performance of the orthodontic phases of treatment are important determinants in the cost structure.

Vakavat sairaudet aiheuttavat merkittäviä taloudellisten resurssien menetyksiä perheissä. Tutkimuksessa tarkastelemme puolison syöpädiagnoosin vaikutuksia terveen puolison työmarkkinalopputulemiin. Tämän lisäksi tarkastellaan perheen kokonaistulojen kehitystä. Vaikutuksia tarkastellaan erikseen nais- ja miespuolisoille. Tutkimuksen analyyseissä käytetään hyväksi koko Suomen väestön kattavia Tilastokeskuksen sekä Terveyden ja hyvinvoinnin laitoksen ylläpitämiä rekisteriaineistoja, joiden avulla voidaan tunnistaa syöpädiagnoosit ja puolisot. Havaitsemme, että syövän heijastusvaikutukset puolison työllisyyteen riippuvat iästä ja sukupuolesta. Eläkeiän lähestyessä syöpädiagnoosi johtaa naispuolisten puolisoiden työllisyyden todennäköisyyden ja ansiotulojen pieneen kasvuun, kun taas miesten tapauksessa vaikutus on päinvastainen. Nuoremmissa ikäluokissa emme kuitenkaan havaitse vastaavanlaisia vaikutuksia. Tuloksia selittänee se, että miehet ovat olleet naisia useammin kokopäiväisessä työssä ennen puolison sairastumista syöpään, joten työn tarjonnan lisääminen on vaikeampaa. Lisäksi koska miesten syövät päättyvät naisia useammin kuolemaan, syövän taloudelliset heijastusvaikutukset puolisolle ovat naisille suurempia. Tämä voi osaltaan vaikuttaa siihen, että puolison sairastuttua syöpään naiset lykkäävät eläköitymistään, kun taas miehet eivät. Tulokset osoittavat myös sen, että kotitalouksien kokonaistulot supistuvat vähemmän kuin ansiotulot. Tulonsiirrot tasoittavat tulosten perusteella siis merkittävästi vakavien sairauksien aiheuttamia tuloriskejä. Tutkimuksemme osoittaa, että vakavat sairaudet muovaavat kokonaisuudessaan varsin vähän suomalaisten perheiden työn tarjontaa koskevia päätöksiä ja työuria. Näiden vaikutusten parempi huomioiminen terveys- ja sosiaalipolitiikassa edesauttaa kuitenkin tulonsiirtojen optimaalista mitoitusta ja tuloriskien tasaamista. Tutkimuksemme osoittaa, että tulonsiirrot ylläpitävät Suomessa perheiden taloudellista vakautta sairaussokkien yllättäessä.

Terveystaloustieteen yksi keskeisimmistä käsitteistä on vaikuttavuus. Vaikutuksella viitataan usein siihen, millaiseksi tutkittavana olevan kohderyhmän kiinnostuksen kohteena oleva vaste kehittyy intervention jälkeen verrattuna tilanteeseen, jossa interventiota ei olisi tehty. Lääketieteessä vaikuttavuutta tutkitaan valtaosin satunnaistettuja kokeita hyödyntäen. Satunnaistettujen kokeiden rooli on perinteisesti ollut vähäisempi yhteiskuntatieteissä, vaikka laajoja yhteiskunnallisia kokeiluita on tehty ainakin 1970-luvulta lähtien. Terveystaloustieteen lisäarvo terveydenhuollon toiminnan järjestämisen työkaluna on nähty ensisijaisesti priorisoinnissa ja resurssien vaihtoehtoisten käyttötarkoitusten systemaattisessa tarkastelussa, ei niinkään vaikutusarvioinnin saralla. Viime vuosikymmeninä otetut menetelmälliset edistysaskeleet taloustieteessä ja niiden sovellukset terveystaloustieteessä ovat edistäneet uskottavien tutkimusasetelmien tärkeää roolia vaikutusarvioinneissa. Monien tärkeiden terveystaloustieteellisten kysymysten tapauksessa varteenotettavin vaihtoehto vaikuttavuuden arviointiin on käyttää kokeellisten asetelmien sijasta havainnoivia kvasikokeellisia asetelmia ja niihin liittyviä ekonometrisiä menetelmiä. Kvasikokeellisten menetelmien merkittävänä etuna voidaan pitää niiden soveltumista moniin tärkeisiin terveyspolitiikkaa ja terveydenhuoltoa käsitteleviin kysymyksiin ja lisäksi se, että menetelmät mahdollistavat uskottavien vaikuttavuus- jakustannusvaikuttavuusarviointien tekemisen vastaavasti kuin satunnaistetut koeasetelmat. Tässä artikkelissa esitellään satunnaistetut ja keskeisimmät kvasikokeelliset tutkimusasetelmat sekä niitä hyödyntäviä suomalaisia ja kansainvälisiä terveystaloustieteen tutkimuksia. Lisäksi artikkelissa arvioidaan ns. uskottavuusvallankumouksen vaikutusta terveystaloustieteelliseen tutkimukseen. Yhtenä tavoitteena on myös havainnollistaa opiskelijoille ja tutkijoille kvasikokeellisten asetelmien hyödyntämisen mahdollisuuksia erilaisissa ajankohtaisissa sosiaali- ja terveydenhuoltoa käsittelevissä kysymyksissä.

This paper analyzes the long-term effects of potentially avoidable C-sections on children's health. Using Finnish administrative data, we document that physicians perform more unplanned C-sections during their regular working hours on days that precede a weekend or public holiday and use this exogenous variation as an instrument for C-sections. We supplement our instrumental variables results with a differences-in-differences estimation that exploits variation in birth mode within sibling pairs and across families. Our results suggest that avoidable unplanned C-sections increase the risk of asthma, but do not affect other immune-mediated disorders previously associated with C-sections.

Objectives: To clarify the diagnostic utility and the cost-effectiveness of whole-exome sequencing (WES) as a routine early-diagnostic tool in children with progressive neurological disorders. Methods: Patients with infantile-onset severe neurological diseases or childhood-onset progressive neurological disorders were prospectively recruited to this WES study, in the pediatric neurology clinic at Helsinki University Hospital during 2016-2018. A total of 48 patients underwent a singleton WES. A control group of 49 children underwent traditional diagnostic examinations and were retrospectively collected from the hospital records. Their use of health care services, related to the diagnostic process, was gathered. Incremental cost-effectiveness ratio (ICER) per additional diagnosis was calculated from the health care provider perspective. Bootstrapping methods were used to estimate the uncertainty of cost-effectiveness outcomes. Results: WES provided a better diagnostic yield (38%) than diagnostic pathway that did not prioritize WES in early diagnosis (25%). WES outperformed other diagnostic paths especially when made early, within one year of first admission (44%). Cost-effectiveness in our results are conservative, affected by WES costs during 2016-18. Conclusions: WES is an efficient and cost-effective diagnostic tool that should be prioritized in early diagnostic path of children with progressive neurological disorders. The progressively decreasing price of the test improves cost-effectiveness further. (C) 2021 The Authors. Published by Elsevier Ltd on behalf of European Paediatric Neurology Society.

Mass vaccination is effective in reducing SARS-CoV-2 infections among vaccinated individuals. However, it remains unclear how effectively COVID-19 vaccines prevent people from spreading the virus to their close contacts. Using nationwide administrative datasets on SARS-CoV-2 infections, vaccination records, demographics, and unique household IDs, we conducted an observational cohort study to estimate the direct and indirect effectiveness of mRNA-based COVID-19 vaccines in reducing infections among vaccinated healthcare workers and their unvaccinated household members. Our estimates for adults imply indirect effectiveness of 39.1% (95% CI: -7.1% to 65.3%) two weeks and 39.0% (95% CI: 18.9% to 54.0%) eight weeks after the second dose. We find that the indirect effect of mRNA-based COVID-19 vaccines within households is smaller for unvaccinated children than for adults and statistically insignificant. Here, we show that mRNA-based COVID-19 vaccines are associated with a reduction in SARS-CoV-2 infections not only among vaccinated individuals but also among unvaccinated adult household members in a real-world setting.

We are very happy to provide the very first issue of the Journal of the Finnish Economic Association (JFEA). JFEA is a new peer-reviewed international journal published biannually by the Finnish Economic Association and it replaces the Finnish Economic Papers. The objective of JFEA is to provide a high-quality and fast peer-reviewed publication channel for applied economic papers, and facilitate communication of topical research results to the research community and policymakers.

We are very happy to provide the very first issue of the Journal of the Finnish Economic Association (JFEA). JFEA is a new peer-reviewed international journal published biannually by the Finnish Economic Association and it replaces the Finnish Economic Papers. The objective of JFEA is to provide a high-quality and fast peer-reviewed publication channel for applied economic papers, and facilitate communication of topical research results to the research community and policymakers.

Abstract: This paper studies the direct and indirect effectiveness of Covid-19 vaccines among vaccinated healthcare workers and their unvaccinated adult household members in a mass vaccine program in Finland. Methods: We used national databases that record all polymerase chain reaction (PCR)-confirmed SARS-CoV-2 infections and mRNA-based (BNT162b2 by Pfizer-BioNTech or mRNA-1273 by Moderna) vaccine doses administered in Finland since the beginning of the epidemic. These data were merged with administrative full population datasets that include information on each person's occupation and unique identifiers for spouses living in the same household. To estimate the direct and indirect effectiveness of mRNA-based vaccines in a household setting, we compared the cumulative incidence of PCR-confirmed SARS-CoV-2 infections between vaccinated and unvaccinated healthcare workers as well as between their unvaccinated spouses. Findings: Our estimates imply indirect effectiveness of 8.7% (95% CI: -28.9 to 35.4) two weeks and 42.9% (95% CI: 22.3 to 58.1) 10 weeks after the first dose. The effectiveness estimates for unvaccinated household members are substantial, but smaller than the direct effect and occur more gradually among unvaccinated household members than among vaccinated individuals. Interpretation: Our results suggest that mRNA-based vaccines do not only prevent SARS-CoV-2 infections among vaccinated individuals but lead to a substantial reduction in infections among unvaccinated household members. The results are consistent with the notion that mRNA-based vaccines affect susceptibility in vaccinated individuals and prevent transmission from vaccinated to unvaccinated individuals.

OBJECTIVES:Clinical diagnostics in adults with hereditary neurological diseases is complicated by clinical and genetic heterogeneity, as well as lifestyle effects. Here, we evaluate the effectiveness of exome sequencing and clinical costs in our difficult-to-diagnose adult patient cohort. Additionally, we expand the phenotypic and genetic spectrum of hereditary neurological disorders in Finland.METHODS:We performed clinical exome sequencing (CES) to 100 adult patients from Finland with neurological symptoms of suspected genetic cause. The patients were classified as myopathy (n = 57), peripheral neuropathy (n = 16), ataxia (n = 15), spastic paraplegia (n = 4), Parkinsonism (n = 3), and mixed (n = 5). In addition, we gathered the costs of prior diagnostic work-up to retrospectively assess the cost-effectiveness of CES as a first-line diagnostic tool.RESULTS:The overall diagnostic yield of CES was 27%. Pathogenic variants were found for 14 patients (in genes ANO5, CHCHD10, CLCN1, DES, DOK7, FKBP14, POLG, PYROXD1, SCN4A, TUBB3, and TTN) and likely pathogenic previously undescribed variants for 13 patients (in genes ABCD1, AFG3L2, ATL1, CACNA1A, COL6A1, DYSF, IRF2BPL, KCNA1, MT-ATP6, SAMD9L, SGCB, and TPM2). Age of onset below 40 years increased the probability of finding a genetic cause. Our cost evaluation of prior diagnostic work-up suggested that early CES would be cost-effective in this patient group, in which diagnostic costs increase linearly with prolonged investigations.CONCLUSIONS:Based on our results, CES is a cost-effective, powerful first-line diagnostic tool in establishing the molecular diagnosis in adult neurological patients with variable symptoms. Importantly, CES can markedly shorten the diagnostic odysseys of about one third of patients.

We study the yield curve control in Eurozone. We apply Chen, Curdia and Ferrero (2012) model that uses a financial friction to break Wallace's neutrality. We calibrate a bond supply shock that corresponds to the observed change in the time premium in euro area when the APP program was introduced. With some model simulations, we show that the effectiveness of both unconventional monetary policy and fiscal policy are enhanced, when the yield curve control is applied. Thus, we find that the yield curve control can be an effective tool, if applied in a credible manner for a long enough time period during an effective lower bound episode.

We study the effects of intergovernmental grants on school spending within the Finnish system of high school education funding. Using a kinked grant rule, the system allocates lump-sum intergovernmental grants to local high school education providers. Utilizing the quasi-experimental variation in grants given by the rule, we identify the effects of the grants on municipal high school education expenditures. Our results indicate that the grants stimulate spending, while local tax rates or revenues do not seem to be responsive to the grants, suggesting the presence of a typical flypaper effect. However, we also consider the possibility that the grant responses might be heterogeneous among municipalities. Based on our heterogeneity results, the grant response is positively associated with the share of the high school age population, and a higher share of elderly persons is related to a lower propensity to spend on education out of grant funding. This result is in line with the idea of intergenerational conflict in education spending preferences presented in education finance literature.

We estimate the effects of health information technology designed to improve access to medication while limiting overuse through easier prescription renewal and improved information provision. We focus on benzodiazepines, a commonly prescribed class of mental health and insomnia medications, which are highly effective but potentially addictive. We study the staggered rollout of a nationwide electronic prescribing system over four years in Finland and use population-wide, individual-level administrative data sets. We find that e-prescribing increases average benzodiazepine use due to increased prescription renewals. The increase is most pronounced for younger patients. E-prescribing can improve the health of elderly patients and may help to balance the access-overuse trade-off. Without additional monitoring for addiction in place, it may, however, also have unintended health consequences for younger patients, who are more likely to develop mental and behavioral health disorders.

The Finnish regional government reform currently under consideration will create a new tier of regional county governments, which will be responsible mainly for the provision of health and social care services. On the revenue side, counties will be financed mostly through grants from the central government and out-of-pocket payments (i.e. client fees). The funding model of the counties raises a number of questions from the point of view of the fiscal federalism literature. One important question in particular is: what kind of incentives will centrally-allocated funding create for the regional governments? One concern raised is that this type of financing structure will create a soft budget constraint for the counties. In other words, the county governments will expect that the central government will provide them with additional resources if they surpass their allocated budget. This paper discusses the potential for soft budget constraints (SBC) in the newly-created Finnish counties, by reviewing contributions from the fiscal federalism literature. Besides providing the overview of the relevant literature, we highlight the determinants of SBC problem most relevant for the Finnish regional government reform and possible solutions. One important conclusion from our discussion is that decentralizing spending alone can lead to softer budget constraints and overspending for the regional governments, due to the vertical fiscal imbalances that it creates. In other words, the spending responsibilities of the county governments might be too large for their revenue-generating possibilities. One channel through which the proposed funding system softens the budget constraint is the possibility for local governments to “blame” the central government for the deficits or fiscal troubles. According to the literature, this problem is particularly relevant for the health care services, since it touches a politically sensitive issue. Another interesting conclusion from our discussion is that it might simply be impossible for the central government to commit to a no-bailout policy. In the case of health and social care provision in Finland, the central government might even explicitly commit to increasing resources ex ante if services are at risk. In this case, the literature suggests having pre-determined mechanisms around the bailouts. Possibilities include mandated austerity measures as conditions for the bailout, or direct central oversight. These measures seem to improve local public finances. Our findings from the fiscal federalism literature also suggest that the reform should proceed with additional tax autonomy at the county level, since that would limit the soft budget constraints and improve the fiscal performance of counties.