The Healthcare insurance act and primary care in the Netherlands

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2. contents
• Healthcare insurance act
– Regulated competiton model and role of HIC
• Primary care covered by the HIA
– Role of Primary Care
• Recent cases
– Primary care obstetrics
– Hospital and primary care emergency services
• Conclusions from cases
• Recently proposed changes in HIA
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3. Healthcare insurance act
• Two part insurance system (public/private) until 2006
• Reform discussion healthcare insurance system started in 1987 (!) when
present system was outlined
• Healthcare insurance act introduced in 2006
• Key elements:
– Mandatory healthcare insurance, universal coverage
• Basic package determined by Health ministry
– Both nominal fee and income dependent fee (>18 yrs.)
• Mandatory deductible (€ 220 p.a.)
– Private healthcare insurance companies
• Acceptance obligation
• Elaborate risk equalisation scheme
– Different types of policy:
• Care in kind, contracted by insurance company
• Reimbursement policy
• combination
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4. Healthcare insurance act does not cover all health care
Healthcare
Regional Care
insurance procurement office municipalities
companies
Social
Exceptional
Healthcare support
medical
insurance act act
expenses act
• Primary care • Outpatient care • Home care
• Hospital care • Long term admittance • Transportation
• Dental care (< 18 yrs) • Care for elderly • Wheelchairs, adjustment
• Psychiatric care (<1 yr) • Long term psychiatry s to house
• Total expenses: € 37 bln. • Total expenses: € 25 bln. • Meal services
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5. Total expenses under healthcare insurance act (€ mln.)
€ 612
€ 729 € 505
€ 617
€ 1,145
€ 2,324 hospital care
medicines and medical aids
mental health
€ 4,038 GP care
other
€ 20,189 dental care
paramedical assistance
ambulances and transportation
€ 6,827
obstetrics and maternal care
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6. Health insurance act : the regulated competition model
• Two levels of competition
– Competition between insurers
• Consumer has right to switch between insurance companies annually
• Competition on nominal fee, quality and service
– Competition between providers
• Free contracting
• Health insurer carries out targeted and selective contracting
(price/quality)
• Consumer’s preferences for providers
• Health insurers responsible for:
– Controlling expenses
– Controlling total capacity, access
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7. Primary care covered under the HIA
Providers:
care coverage Mandatory Number of Number of Reimbursement
deductible/ co professionals practices
payment
General practice full no 8900 4090 Per registered
patient
Per consultation
Pharmacy/ Registered Yes; co payment 2860 2000 Per prescription
medical aids medication for non preferred
medication
Primary care full No deductible; 2600 1600 Fee for service
obstetrics/ For some care
maternal care services co
payment
Paramedic care Limited yes >17000 >4700 Fee for service
Dental care < 18 yrs no 8400 5600 Fee for service
Health insurance market: highly concentrated, 4 largest insurance groups have
90% market share
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8. Role of primary care
• Gatekeeper model:
– Under HIA, access to specialised (hospital) care is restricted.
Patients need to be referred by their GP, or, depending, by
obstetrician, dentist etc.
• Exception: emergengy medical care
• Direct access to all primary care (except prescription medicine)
– Pivotal role of GP is laid down in HIA
• Consumers are required to register with local GP practice
• Leads to powerful position GP in ‘market’
• Emphasis on primary care and substitution from hospital
care to primary care
• Cost saving
• Quality of living
• Quality of care
• Easy access to local care
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9. Current issues in contracting primary care
• Limited consumer’s choice in GP practice, dentist
• Providers claim there is insufficient room for negotiation
– Standard contracts ( “sign on the dotted line”)
– Little differentiation in quality
– Imbalance between HI companies and care providers
• GP association is opposed to competition
• HIC limit availability of medication
– Coverage limited to generic brands, lowest prices
– Pharmacists face lower income/profit
– Entrance in market has ceased
• No effort HIC in contracting dental care
– Caused end of pilot with price liberalisation
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10. Recent cases
1. Cooperation between primary care
obstetricians and hospitals
2. Integrated primary care and hospital
emergency services
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11. 1.1 Cooperation between primary care obstetricians and hospital
gynecologists
• Background: relatively high infant mortality
– Childbirth at home as standard
• Aim: improved quality of care by integrated approach
• National steering committee published guidelines (2009)
– Better coordination of care
– Sharing medical information
– Transfer of patients
• Resulting in:
– Change in professional guidelines for treatment
– Change in attitude
– New ways of organizing care
• ‘childbirth centres’ for outpatients
• Remaining (legal and practical) barriers : tariff
structure, health insurance act (co payment)
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13. 1.2 Cooperation between primary care obstetricians and hospital gynecologists
• City of Apeldoorn
– 157.000 inhabitants
– 1 hospital
– 4 primary care obstetric practices
• Hospital and 1 practice started corporation
– Practice with outpatient birth centre, built annex to hospital
– Easy access to diagnostics, hospital facilities
• 3 health insurers in region
– Reluctantly supporting initiative
– Cost issues (hospital contract)
– Access for other primary care patients without surcharge
• Initiative is functioning as of april 2012
– Resources of hospital (infrastructure, financing,management support))
– Quality driven primary care provider
– Support of hospital medical staff
• NZa recommendations:
– Level playing field primary and specialised (hospital) care
• Tariff structure, change in co payments
• Integrated payment for integrated care services
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14. 2.1 Cooperation between hospital emergency services and
primary care
Background:
• GP services cover both high and low urgency care
– Patient is supposed to visit GP where he/she is registered for urgent care
whenever possible
• Change in the GP profession: increasing number of group practices,
relatively small scale, increasing part time work
• Other organisation:
– GP services during office hours: GP’s practice
– ENW: GP emergency care station
• Cooperating GPs covering region (see map)
• Separate organisations, different compensation model
• Ca. 95% of GPs participate
• Changing behaviour of patients:
– Visiting hospital emergency department instead of GP
– Going to GP emergency station (evening) instead of ‘their’ GP (office hours)
– Resulting in higher cost
– Inefficiency in handling patients
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16. 2.2 Cooperation between hospital emergency services and
primary care
• Central region , approx. 130.000 inhabitants
• 1 hospital, approx. 8 GP practices
• Corporation (hospital/GP)founded
– Covering regional emergency service evenings/nights
– Agreement reached 2007: Additional payments to GPs by health insurer (with largest local
market share) and hospital: shared savings model, allowing payment of higher hourly rates
to GPs.
– Corporation started functioning in 2008
– One central triage system sees all patients without referral
• 75% is seen
• 16% of total is referred to hospital emergency department
• Corporation quit in 2010
– Health insurance company pulled out
– GPs not prepared to put in more hours at present rates
• NZa recommendations:
– More leeway for local experiments
– Abolish maximum hourly compensation for GP services in ENW
– More flexible organisation of GP services during office hours and evenings
– Introduce more alternatives for funding triage
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17. Some conclusions from the cases
• Initiative to reorganize care lies with providers
• HIC often reluctant to participate
– Regulation
– Free rider problem
– Manpower shortage
• HIC not leading in fundamental changes
• Providers operate regionally, yet require commitment from all insurers. This can
make negotiations complex.
• Hospitals tend to support local primary care
– Commercial interest
– Strong foothold in regional care, strenghtening bargaining position with health insurers
– Need to improve efficiency
– Quality improvement
• NZa recommendations to improve regulatory model:
– Further strenghten the role of insurers
– Abolish unnecessary regulatory obstacles
– Introduce new methods in funding and encourage local pilots
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18. Recently proposed changes in HIA
• Financing the health care insurance act:
– Controversy over income dependent part of HI fee
• Proposal to shift financial burden to middle and higher income groups
• New plans still unclear
– Introduction of income dependent mandatory deductible
• Only ‘care in kind’ policy allowed
– Strengthening bargaining position HIC and limiting consumer’s choices
• Compensation for GPs and hospital emergency services will be
changed (regional budget, based on number of inhabitants)
• Emphasis on cooperation in stead of competiton
• More attention to differences in quality of care
• These proposals challenge some of the fundamental principles of
the present health care insurance system.
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19. Thank you for your attention!
For further information please contact:
Dutch Healthcare authority
Johan van Manen
T: +31 (30) 2968 171
E: jmanen@nza.nl
W: www.nza.nl
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