Contracted to Care: Capitation or Decapitation?

This essay was hardly planned, but I reckon it’s doable, considering I’ve covered this in previous essays, at least twice or so, albeit those times it’s been more of a general examination of what’s at stake. Anyway, to get to the point, I came across a news story about the planned changes for the social and healthcare sector in Finland, in which these sectors would be revamped and rearranged, moving them from the municipalities to regional entities to be created in the process. If you are a Finn, you know this discussion and planning has been going on and on, for ages now. I’m hardly an expert on this and I acknowledge that I should do a better job with this, keep tabs on this, but this just so that people won’t think that I know what’s what with this. The problem is, to my understanding, that the planned changes are so massive that no one really knows how it will turn out and what the long term effects are going to be. This is also why this is very much something that should be scrutinized. The complexity of it all is bound to make it prone to … all kinds of subtle foul play, kind of like gerrymandering, sneaking in a bit of this and that, as suggested by various parties that have an interest in the issue. While this is arguably what should be paid attention to, this essay is not on that, as such, but rather at what is going to or may happen if these changes to social and health care sector go through.

Anyway, to cut to the chase, I came across a story in Helsingin Sanomat titled ‘Uusi tieto sote-uudistuksesta: Jokainen suomalainen pisteytetään sen mukaan, miten paljon hän rasittaa terveydenhuoltoa’ by Anni Lassila, as published on 10.4.2018. If you can’t read Finnish, not many can in the world, it’s indicated in the title that as part of the changes to be made each and every Finn, I assume Finnish national and/or anyone entitled to services of the social and healthcare sector, that is to say taxpayer, will be evaluated and judged on a point system as to how much they are a burden to healthcare. As I pointed out, I haven’t really delved into the topic, beyond what gets discussed every now and then, but just by judging the title, the headline, holy biopower, the …ing what now!? Okay, let’s step back for just a moment and keep it cool. Maybe the title is just misleading. I mean that can happen. So, let’s keep going. It is stated in the lead paragraph that “Sote-keskus saisi asiakkaasta yksilökohtaiseen riskiin perustuvan maksun. Sen laskennassa otettaneen huomioon niin terveyshistoria kuin niin sanotut sosioekonomiset tekijät.” What that means to any reader unable to comprehend Finnish is that the … no, not the patient … but the customer, would undergo risk assessment, in which prior medical records would be taken into account, as well as so called socioeconomic factors. Now, this is explained as having to do with the money involved, the compensation made to the health care provider, be it public or private, or so I gather anyway. Further in in the story, it is stated that it is intended that people themselves do not know of these, how expensive or cheap they are according the aforementioned factors. This has to do with how the health care provider is compensated on a yearly or monthly basis. So, the way I understand this is that as one can choose one’s health care provider at a certain interval, the money is to flow to that entity accordingly. Now, the way I read this is that it does not have to do with your actual use of the said services, but rather the deemed … or should we say suspected … health care needs based on your profile that is stitched for you based on your previous history and … those other factors, like it or not. The logic here is, as explained in the story, that when people are judged accordingly, the health care provider is or will not be incentivized to attract healthy individuals who don’t end up using the services, yet get compensated for it at certain intervals. Now, to be honest, this makes perfect sense. Providing health care to healthy people is way better a business than providing it to unhealthy people if the price is exactly the same. You’d do your best as a business owner to just attract people with the least risk of this and that, calculating it to perfection. This is what I like to call min-maxing, making the best out of something with the least effort or investment involved.

What’s suggested here hardly comes across as dystopian. In a way that makes sense, to prevent the health care providers from working the angles to just maximize their profits by catering to the right customer base. What’s actually dystopian about this is that the state, as represented in the story by an expert, labeled with the title, along the lines of head of research of the National Institute for Health and Welfare, best known locally as THL, does not see a single issue with coming up with (in)dividualized profiles for people based on various factors, which can be judged accordingly by harvesting the data of the person that exists in all of the state registries that are, to my knowledge, kept separate for, erm., how should I put it, for a reason, a reason most often referred to as privacy. Moreover, the expert goes on record to state that currently there are issues with keeping proper records on people and that is area that could use improvement. To my understanding the various registries are kept for specific purposes, purposes that bear relevance to those who work with people on this and/or that. So, for example, as it is pointed out, there’s a healthcare registry. Now, the way I see it, it sort of makes sense that your doctor or your dentist has a record of what was done to you previously. Similarly, it sort of makes sense that a social worker knows the situation or that the tax authority knows who is liable for what and has stated what in their tax report. It’s worth emphasizing that these are separate and it takes quite a bit of foul play for the authorities to be allowed to look at things that don’t come with the territory. This is, to my understanding, intentional. Imagine if your dentist had your tax records, just so that the dentist knows your socioeconomic situation. Okay, I reckon they wouldn’t know such under this model. Then again, if you have a good health record, yet the health care provider is provided with a hefty compensation. How is that not a sign of someone being in a socioeconomically disadvantaged position in the society? How’s that the business of the health care provider if someone is or isn’t this and/or that, beyond what matters, what works for the provision of health care for that pat… I mean, sorry, customer. The way I read this, as confirmed by the area of expertise of the said expert, economics, all that matters is money, how to min/max.

Now, to be fair, the expert is not trying point the finger at people, to judge them for being a burden. Also, the way I interpret this is that this wouldn’t exactly concern people more than it currently does. There’s that. Then again, I fail to understand how the said expert doesn’t think that gathering people’s data, kept in separate registries, for the very purpose of having a need to know basis, with certain exceptions under certain stringent conditions, and consolidating them into one database is a good idea. While it may indeed lead to more productivity, more efficiently, hence the min/max angle that I keep bringing up, it’s not like you cannot make use of this data kept on everyone for other purposes. That may not be now, nor within anyone’s interest in the foreseeable future, but this is offers the state some next level targeting capabilities, especially when it’s not just about medical conditions, this or that, that are kept tabs on, but other … socioeconomic factors, that is to say your tax records, as well as any non-medical services used. It only makes this worse that the expert states that the currently there’s sloppiness when it comes to record keeping. So, to make this very, very concrete, how would you like that the state, as represented by whoever it is at whenever it is in the future, looking at you like, oh, right, judging by your socioeconomic situation, compounded with your health care record, and the record of your family, known for having this and that condition, you’ll be at risk of failing at life, so how about we dictate how you should live your life. Alternatively, let’s put it the other way around, you’ll get to live your life the way you want, maybe be given incentives like tax reductions, as long as your record is clean, of this and that. The problem is that what may be just fine now may not necessarily be fine down the road. It gets even better as one is not supposed to be made aware of one’s evaluation, how (in)expensive you are. What if there’s information that the person has indeed to provided to authorities but it has been put on record incorrectly? So, does the person have no right to examine its own profile and object to incorrect information that has been put on record. Would you not be able to put in information that is deemed as a positive or a negative, regardless of how things are? I’d say yes, that’s sort of obvious that people may start gaming the system, perhaps in exchange of this and/or that that is kept not kept on record.

Then there’s also the other considerations, not only of the state. It’s not exactly uncommon that data gets compromised, so keeping centralized data on people, on essentially everything that they do under the consideration tiled as socioeconomic factors, is simply a terrible idea, not to mention seriously, if not hilariously, naive. Imagine that data being leaked to third parties, yeah, sure, it’s not like they wouldn’t target an individual when they have their full records on just about everything. How to put it as simply as I can? Well, there’s just something really absurd about going all in on profiling people when that’s exactly what people find problematic, (pre)judging people on the basis of this and/or that. Something tells me that the expert cited in this story hasn’t read much literature outside his own field of expertise. Okay, perhaps that’s not fair. That said, something still tells me that he hasn’t read much of Michel Foucault, especially not anything by him on biopower, considering that it’s, more or less, the crux of how to min/max the population, the get all the juice out of people during their lifetime, maxing their output during lifetime, while minimizing any costs associated to it. This is also not just about this versus that, but also what gets deemed as this or that, who gets to judge what is a deemed risk or a detriment that affects these calculations. One way or another, knowing what I know, unlike the cited expert, it seems, I can’t exactly buy this as being interest of the people, except, perhaps a select few people, now or in the future. This reeks of biopower and it won’t go away no matter how much you sugarcoat it as giving people more options, as by the people for the people. What is suggested is straight out of an episode of Charlie Brooker’s ‘Black Mirror’, keeping a record of people, on a point system, of all things. Assuming that this is all well and good in terms of the presentation, the only thing, or rather one, worth commending here, chapeau, is, the journalist.


  • Jones, A., and C. Brooker (Ex. Pr.) (20112019). Black Mirror (C. Brooker, Cr.). London, United Kingdom: Zeppotron / House of Tomorrow.
  • Lassila, A. (10.4.2018). Uusi tieto sote-uudistuksesta: Jokainen suomalainen pisteytetään sen mukaan, miten paljon hän rasittaa terveydenhuoltoa. Helsinki, Finland: Helsingin Sanomat.