THE WORLD BANK IBRO * IDA I WORLD BANKGROUP ARUP BANERJI Regional Director for Operations European Union Countries OFFICIAL Europe and Central Asia DOCUMENTS June 1,2017 Mr. Tanel Ross Chairman of Management Board Estonian Health Insurance Fund Lembitu 10 10114 Tallinn, Estonia Dear Mr. Chairman: Subject: Estonian Health Insurance Fund Reimbursable Advisory Services Agreement No 2-10/162 - Amendment Letter This is in reference to the Reimbursable Advisory Services Agreement dated December 31, 2015 ("RAS Agreement") between the Estonian Health Insurance Fund ("Client") and the International Bank for Reconstruction and Development ("Bank"). We also refer to an email dated February 7, 2017 from your designated representative requesting an amendment to the timeline of deliverables in the RAS Agreement and an extension of the closing date, and an email dated May 19, 2017 confirming recent discussions between our teams regarding a new deliverable: an evaluation brief of the care management pilot to be added to the RAS Agreement. We are pleased to inform you that after due consideration, the Bank concurs with the above requests, and the RAS Agreement is hereby amended as follows: 1. Paragraph 4 of the RAS Agreement is amended to read as follows: "4. Payment (a) The Client shall pay the Bank a fixed fee of four hundred fifty thousand Euros (EUR 450,000) in accordance with the following schedule ofpayment: Amount of Event upon which Payment Is Due Installment EUR 200,000 Upon submission ofthe brief on patient comorbidity analysis and the presentation on the proposed methodology to assess waiting times referred to in Section B ofthe Schedule to this Agreement EUR 100,000 Upon submission of the summary report on the waiting times analysis referred to inSectionB ofthe Schedule to this Agreement EUR 140,000 Upon submission ofthe summary report on the risk-stratification model referred to in Section B ofthe Schedule to this Agreement EUR 10,000 Upon submission of the evaluation brief of the care management pilot Avenue Marnix 17 * B-1000 Brussels * BELGIUM Tel: +32.2.504.0994 Mr. Tanel Ross -2- June 1, 2017 2. Paragraph 6 of the RAS Agreement is amended to read as follows: "6. Expiration. This Agreement shall expire on October 15, 2017 unless it shall earlier be renewed with the mutual agreement of the Client and the Bank." 3. Component 1: Patient at risk registry, under Section A of the Schedule to the RAS Agreement is amended to read as follows: "The Bank will propose a methodology for a patient at risk registry to identify patients that would benefit most from care management in Estonia. This will include: (i) an analysis of comorbidity patterns prevalent in Estonia: (ii) a review of available risk stratification models (e.g., Charlson Comorbidity Index, Chronic Comorbidity Count, Scottish Patients at Risk of Readmission and Admission. etc.); (iii) participation in a workshop to define the objectives of the risk-stratification model (e.g., reducing avoidable admissions); (iv) a pilot of the methodology using 2008-2014 medical claims and e-prescription data; (v) an operations manual documenting the data collection processes and analytical methods used for the risk stratification model based on medical claims and e-prescription data; (vi) an evaluation of the care management pilot including a proposal on how EHIF can price the care management package in an activity-based manner; (vii) the development of a guideline for family physicians to use their first-hand knowledge of their patients to help narrow down patients included in the at risk registry and a pilot of these guidelines amongst a small group of family physicians; (viii) the development of a performance monitoring framework to assess progress in achieving the objectives of the patient at risk registry; and (ix) participation in a workshop with relevant health sector stakeholders to elaborate an implementation plan for the patient at risk registry and its potential applications in future service delivery reforms." 4. Component 1: Final Deliverables under Section A of the Schedule to the RAS Agreement is amended to read as follows: "Final Deliverables: 1. A summary report on results of the risk-stratification model based on medical claims and e-prescription data; 2. An operations manual documenting the data collection processes and analytical methods used for the risk stratification model based on medical claims and e- prescription data; 3. A guideline for family physicians to use their first-hand knowledge of their patients to help narrow down patients included in the at risk-registry; 4. A performance monitoring framework to assess progress in achieving the objectives of the patient at-risk registry- and 5. An evaluation brief of the care management pilot including a proposal on how EHIF can price the care management package in an activity-based manner. Intermediate Deliverables: 1. A power point presentation describing the proposed methodology for risk- stratification model based on medical claims and e-prescription data, after consultation with relevant stakeholders; and Mr. Tanel Ross -3- June 1, 2017 2. Briefs on the: (i) results of the patient comorbidity analysis; and (ii) review of available risk stratification methodologies." 5. The Timetable under Section B of the Schedule to the RAS Agreement is amended to read as follows: Deliverable Months from Contract Signing Component 1. Patient at risk registry - Brief on patient comorbidity analysis 1 month - Brief on review of available risk-stratification methodologies 3 months - Presentation on describing the proposed methodology for risk- 6 months stratification model based on medical claims and e-prescription data - A guideline for family physicians to help narrow down patients 10 months included in the at-risk registry - A performance monitoring framework to assess progress in 12 months achieving the objectives of the patient at-risk registry - A summary report on results of the risk-stratification model based 17 months on claims and e-prescription data - An evaluation brief of the care management pilot including a 21 months proposal on how EHIF can price the care management package in an activity-based manner - An operations manual documenting the data collection processes 21 months and analytical methods used for the risk stratification model using medical claims and e-prescription data) Component 2. Waiting times analysis - Presentation on proposed methodology to assess waiting times 1 month drawing on established measures and methods from the OECD, as well as others that are (and will be) newly developed by the Bank in collaboration with medical experts - A summary report on findings of the analysis on patient waiting 8 months times in 2014 - An operations manual describing data collection and analytical 11 months methods used to assess waiting times Component 3. Policy advice - Policy brief on payment system for primary care 7 months - Policy brief on gatekeeping and referral system 7 months - Policy brief on surgical day care 8 months Please confirm the Client's agreement to the foregoing amendments by countersigning and dating the confirmation set forth below, and returning one fully signed original of this letter to us for our files. One fully signed original should be retained by the Client. Mr. Tanel Ross -4- June 1, 2017 Except as specifically amended in this letter, all other provisions of the RAS Agreement remain in full force and effect. Upon receipt by the Bank of the original of this letter countersigned by the Client's authorized representative, the above amendments shall become effective as of the date of countersignature of this Amendment Letter. Sincerely, Regional Director European Union Countries AGREED: REPUBLIC OF ESTONIA By : Name m e:_ Title :a Date :4-O 019* cc: Maivi Parv, Member of the Management Board, EHIF Pille Banham, Member of the Management Board, EHIF Silja Kimmel, Chief Analyst, Department of Health Care and Communications, EHIF