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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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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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Healthcare insurance act

Exceptional medical

expenses act

Social support

act

Healthcare insurance

companies

Regional Care procurement office municipalities

Healthcare insurance act does not cover all health care

• Primary care• Hospital care• Dental care (< 18 yrs)• Psychiatric care (<1 yr)• Total expenses: € 37 bln.

• Outpatient care• Long term admittance• Care for elderly• Long term psychiatry• Total expenses: € 25 bln.

• Home care• Transportation• Wheelchairs,

adjustments to house• Meal services

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Total expenses under healthcare insurance act (€ mln.)

€ 20,189

€ 6,827

€ 4,038

€ 2,324

€ 1,145

€ 729 € 617 € 612 € 505

hospital caremedicines and medical aidsmental healthGP careotherdental careparamedical assistanceambulances and transportationobstetrics and maternal care

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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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Primary care covered under the HIA

care coverage Mandatory deductible/ co payment

Number of professionals

Number of practices

Reimbursement

General practice full no 8900 4090 Per registered patientPer consultation

Pharmacy/ medical aids

Registered medication

Yes; co payment for non preferred medication

2860 2000 Per prescription

Primary care obstetrics/maternal care

full No deductible; For some care services co payment

2600 1600 Fee for service

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 have90% market share

Providers:

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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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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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Recent cases

1. Cooperation between primary care obstetricians and hospitals

2. Integrated primary care and hospital emergency services

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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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• 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

1.2 Cooperation between primary care obstetricians and hospital gynecologists

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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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• 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

2.2 Cooperation between hospital emergency services and primary care

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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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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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Thank you for your attention!

For further information please contact:Dutch Healthcare authorityJohan van ManenT: +31 (30) 2968 171E: jmanen@nza.nlW: www.nza.nl