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Health(care)
in the Netherlands
International Visitors Programme 2017
Workshop
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09:00 Welcome by ModeratorPeter Post, Director, Task Force Health Care
09:05 Welcome & OpeningAngelique Berg, Director General, Ministry of Health, Welfare & Sport
09:15 The Dutch Health(care) System: Accessibility,
Quality & AffordabilityProf. Dr. Patrick Jeurissen, Chief Research Scientist,
Ministry of Health, Welfare & Sport
10:00 eHealth in the NetherlandsLies van Gennip, Director, Nictiz
(National Competence Centre for Standardisation & eHealth)
10:30 Coffee Break
10:45 Parallel Sessions
12:00 Networking Lunch
13:00 End
Agenda
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Warm welcome!
热烈欢迎
Sawubona
Gorąco witamy
Herzliches Willkommen
Muito bem-vinda
Добро дошли
Karibu sana
ترحيب حار
Fàilte
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09:00 Welcome by ModeratorPeter Post, Director, Task Force Health Care
09:05 Welcome & OpeningAngelique Berg, Director General, Ministry of Health, Welfare & Sport
09:15 The Dutch Health(care) System: Accessibility,
Quality & AffordabilityProf. Dr. Patrick Jeurissen, Chief Research Scientist,
Ministry of Health, Welfare & Sport
10:00 eHealth in the NetherlandsLies van Gennip, Director, Nictiz
(National Competence Centre for Standardisation & eHealth)
10:30 Coffee Break
10:45 Parallel Sessions
12:00 Networking Lunch
13:00 End
Agenda
Going Dutch? If “context”
is not transferrable what
remains?
Prof. dr. Patrick Jeurissen
The Netherlands: Average health(Healthy) live expectancy Female smokers
NL
SE
IT
How expensive is Dutch ‘care’?
6
7
8
9
10
11
12
1983 1988 1993 1998 2003 2008 2013
Netherlands European Average
A-typical growth pattern (% GDP)Health expenses EU member states
(%GDP)
Understanding the context of Dutch healthcare:
institutional constraints that withstood ‘reforms’
• Maximizing risk-solidarity (OUP expenses; benefit basket; risk-adjustment;
egalitarian health outcomes; community rating; open enrolment)
• Gatekeeper is the family physician (increases risk-solidarity)
• Self-employed hospital doctors (exception university clinics)
• Large general acute-care nonprofit hospitals; care normally ‘around-the-
corner’
• High penetration tertiary care, very high research outputs
• Average hospital care sector; large long-term care sector
• Stewardship: consensus-based governance model
• Low volumes, high prices?
High use of longterm care
3036
42
72
1983 1990 1997 2010
Per capita square meters in nursing homes
Proportion population receiving formal LTC
Going Dutch? Reforms at work?
Corrective governance mechanisms
Open enrolment &
universal coverage
Multiple payers
(Selective) purchasing
Hospitals
Provider innovation
(Higher) productivity
StewardshipMOH: systemMOF: global budget
Agencies
IndependentCentral bankCompetition authorityCentral economic bureau
Arms-lengthHealth market authorityHealthcare Institute
InspectoratesPatient safetyFraud and abuse
Semi-private governanceSocial-economic councilCovenants: building coalitionsCredit enhancementProfessional standardsInterest groups
1. Community rating 2. Deductible3. Subsidies for lower
incomes4. 50% payroll tax
1. Solvency setting2. Risk adjustment3. Group contracts4. Indemnity /
Managed care
1. VBID2. Selective
purchasing / P4P3. Free rates (70%)4. Quality indicators
1. Independent non-state facilities2. Free investments (>90%)3. State-of-the-art quality4. (Self-employed) physicians5. Free-provider-choice
Assessment: ten years ‘market reforms’
Corrective governance mechanisms
Open enrolment &
universal coverage
Multiple payers
(Selective) purchasing
Hospitals
Provider innovation
(Higher) productivity
1. Uninsured: 194.000 (2009) to 20.000 (2016)2. Switching: 3.6% (2006) to 7.3% (2015)3. Avg. flat premium: €1226 (2012) t0 €1203 (2016)
1. Solvency: 17% (2006) to 27% (2014)2. Overhead: 4.5% (2006) to 3.2% (2014)3. Groups: 55% (2006) to 69% (2012)4. Some mergers
1. Few changes market share (3%)2. Volume caps and budgets (>90%)3. Few price conversions
1. Solvency: 9.1% (2004) to 21.5% (2015) 2. Overhead: 19.79% (2011)3. Price increases 2006 to 2009: 9.5% (A) and 4.8% (B)4. # Hospitals: 99 (2005), 84 (2014)
1. ASC: 37 (2006) to 176 (2011)2. FP Hospitals: 2 (2009)3. Outpatient clinics: 61 (2009) to
112 (2014)
1. Hospital productivity: 2.5%2. Avg. length-of-stay: 7.9 (2002)
to 4.7 (2010)3. No waiting lists
Diffusive policy paradigms in LTC
New services
Core residential
UniversalTarget groups
Client demands
Fixed provisions
How to assess clients?
Longterm care divided
Cost control 2012 – 2016: so far so good?Table: Forecasted and real average flat premium (€)
Over(under) spending BKZ (mrd. €) Increasing solvency (% total assets)
′06 ′07 ′08 ′09 ′10 ′11 ′12 ′13 ′14 ′15 ′16
Forecast 851 879 1057 1074 1085 1211 1222 1273 1226 1211 1243
Realization 771 848 1050 1059 1095 1199 1226 1213 1098 1158 1203
Difference 78 31 7 15 -10 12 -4 60 125 53 40
Why has fiscal sustainability improved recently? Less growth in health expenses (2012 – 2016)
1. increase deductible, abolishing certain financial compensations for chronically ill
2. risk-bearing insurance companies
3. national covenants (to limit growth in expenses)
4. limiting budgets for long-term care
5. devolving services to municipalities
Ending risk equalization
Also more financial risk by patients
′11 ′12 ′13 ′14 ′15
none 94% 93,1% 90,3% 89% 88%
€100 1,4% 1,4% 1,4% 1,4% 1,4%
€200 0,9% 0,9% 1,1% 1,3% 1,3%
€300 0,8% 0,9% 0,7% 8% 0,7%
€400 0,1% 0,1% 0,2% 0,2% 0,2%
€500 2,7% 3,6% 6,2% 7,3% 8,3%
Voluntary deductible
Less patients/clients and rapid growth capital investments
2008 2009 2010 2011 2012 2013
polikliniek 405 400 403 408 384 393
(dag)opname 226 239 251 265 268 246
overig ziekenhuis 521 544 543 578 618 667
V&V zzp > 4 142 156 158 163 186 170
V&V uren 143 148 151 180 184 178
VG verblijf 170 181 181 189 195 194
VG dagbehandeling 589 561 529 529 523 502
# patients and clients (1980 = 100)Increasing volume of capital
hospitals (1980 = 100)
Less patient volumes, an affordable solution?
Per capita expenses pharmaceuticals(Day) treatments per 1.000 inhabitants
Active purchasing? Few changes in provider market shares
Active purchasing in vitro fertalization?
0%5%
10%15%20%25%30%35%40%45%50%
Succesrate (5-year average)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1996 1998 2000 2002 2004 2006 2008 2010 2012 2014
AMC
VU
Marketshare Amsterdam
Some conclusions
• Regulated competition and fiscal sustainability may align (2012 -2016)
• Be hesitant with incentives that only target lower volumes
• Increases in technical efficiency (less waste) more important than increases in co-payments or benefit reductions
• Efficiency: steering on best-practices
• Aligning trends in epidemiology/technology and budgetary policy
• Possibilities for fiscal enforcement are needed (MBI)
• Do not disturb intrinsic motivation by professionals
What makes a healthcare system sustainable?
Good performance on 1) access, 2) quality, 3) efficiency, affordability
No ‘golden’ bullets from a health system perspective (OECD, 2010) & very difficult to change context by policy reforms
Powers for endogenous improvements more important:1) To ‘innovate’ along the lines of value/efficiency2) To ‘correct’ for value destroying behaviours
What works according the review peer-reviewed literature, systematic review
Thank you for your attention
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09:00 Welcome by ModeratorPeter Post, Director, Task Force Health Care
09:05 Welcome & OpeningAngelique Berg, Director General, Ministry of Health, Welfare & Sport
09:15 The Dutch Health(care) System: Accessibility,
Quality & AffordabilityProf. Dr. Patrick Jeurissen, Chief Research Scientist,
Ministry of Health, Welfare & Sport
10:00 eHealth in the NetherlandsLies van Gennip, Director, Nictiz
(National Competence Centre for Standardisation & eHealth)
10:30 Coffee Break
10:45 Parallel Sessions
12:00 Networking Lunch
13:00 End
Agenda
eHeathin the Netherlands
Lies van Gennip, PhD
CEO of Nictiz: National competence
centre for eHealth
This presentation
➢Health care system The Netherlands
➢Nictiz
➢How digital is Dutch health care?
➢Two cases:➢Empowering patients
➢Re-using clinical data for quality
High quality healthcareAccording to various international investigations
Well-organised primary care (GP’s)Contributing to quality
- Relatively high
5-10-2017 33
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Nictiz: national competence centre for eHealth• Founded in 2002
• Foundation without commercial purpose
• Information standards for health care, advice on eHealth policy, support eHealth implementation
• ~50 people
• Financing: mainly ministry of health, welfare and sports
• Not: development of technological solutions or infrastructure(s)
5-10-2017 35
Centre of expertise and advisor for government and healthcare field
Access point andKeeper of Information standardsAnd terminology
Partner in national programsFor development and implementationOf standards
The use of eHealth in the Netherlands
Interoperability in the Netherlands
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PWC (2014) European Hospital Survey. Benchmarking Deployment of eHealth services
Dutch eHealth challenges
• The empowered patient that needs to know and enrich his medical information
• Continuity of care, as patients deal with multiple health care providers
• Closing the quality loop: knowing, understanding and managing health care better
➢Need for interoperability, standards, in practice
Dutch eHealth challenge
5-10-2017 41
CBB
CBB
CBB
CBB
HiX
CBB
HiX CBB
For the patient and the doctor?
✓ No more retyping
✓ Re-use of data results in
✓ Correct data for quality register
✓ No more paper handling
National RegisterFor prostheses
HiX ZIB
The Orthopedic
Surgeons response:
“This makes me
happy, this is
saving me time”
5-10-2017 46
Challenges
• Balancing act between bottom up vs top down
• Capture the value of fast growing technology in slowly changing organizations
• Managing expectations and short term benefits; the better is the enemy of the good.
• The asymmetric business case of healthcare
Garden of delights..
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Thank you!
Dr. Lies van Gennip@liesvangennipgennip@nictiz.nl
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10:30 Coffee Break
10:45 Parallel Sessions
ROOM 7.03
Public Health
MAIN ROOM
eHealth
ROOM 7.04
Elderly CareEvidence-based Public HealthMariken Leurs, National Institute for Public Health and Environment
Quality of Care: Dutch Institute for Clinical Auditing (DICA)Wim Smit, Value2Health
eHealth Policy
Ron Roozendaal, Chief Information Officer,
Ministry of Health, Welfare & Sport
Go-FAIR & Personal Health Train
Erik Schultes, Dutch Techcentre for Life Sciences
Privacy & Innovation
Michaël Stekkinger, MRDM
Elderly care in the Netherlands
Martin Holling, Ministry of Health Welfare &
Sport
From PPP to innovation: Fall Prevention
Project TOM
By Nutricia, Veiligheid NL & Philips
Kenya Poland South Africa Serbia Germany United States U.A.E. Brazil China Simultaneous translation English – Chinese
12:00 Networking Lunch
13:00 End
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Thank you!
Improving Healthcare Together
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