Yvonne van Kemenade Health care reforms in the Netherlands 1 July 2006 Yvonne van Kemenade Albert Schweitzer hospital

Yvonne van Kemenade Content Features Dutch HC system Features Dutch HC system Crucial problems? Crucial problems? HC reforms HC reforms Health Insurance Act Health Insurance Act Act: on Contracting, Tariffs, Hospital Facility, Market Regulation (short) Act: on Contracting, Tariffs, Hospital Facility, Market Regulation (short) First Experiences First Experiences Albert Schweitzer Hospital: current policy Albert Schweitzer Hospital: current policy Trends and uncertainties Trends and uncertainties

Yvonne van Kemenade 3. Feautures Dutch System 1. Three compartiments: - Exceptional Medical Expenses Act - Health Insurance Act - Supplementary insurance 2. Private nature HC-organications 3. Private insurance system Transfer Medical Exp Act to HIA Transfer Medical Exp Act to HIA Social Support Act 2007 Social Support Act 2007

Yvonne van Kemenade Reforms in health care: managed/regulated competition Health care expenditure Health care expenditure Fragmentation former situation Fragmentation former situation More responsibilities to parties More responsibilities to parties Competiton, effectivity en efficiency Competiton, effectivity en efficiency Competition within certain conditions Competition within certain conditions Solidarity, universal access, quality Solidarity, universal access, quality

Yvonne van Kemenade Different possibilities in competition ++-- ZBC’s/privateTopclinical care Planned elective careGeneral practitioner Curative careSEH

Yvonne van Kemenade Submarkets curative care Consumer InsurerHC provider HC insurance market HC providing market HC purchase market Government (WZV) (WTG) (ZFW) (ZFW) (EMEA/AWBZ) (Wtz) (Wet MOOZ)

Yvonne van Kemenade Submarkets curative care 2005/6 Consumer Insurance compan.HC provider HC insurance market HC providing market HC puchaser market t HC Authority (WMG) (WTZi) (WTG Expres) (HOZ) (HIA) (EMEA/AWBZ) (HCAllowances/Wet Zorgtoeslag)

Yvonne van Kemenade 1. HCI Act Changes HC consumer Same conditions insured and insurers Same conditions insured and insurers 1 compulsory health insurance 1 compulsory health insurance Basic benefit package + co- payments Basic benefit package + co- payments Functional claims Functional claims Premium: nominal (>18year) & Premium: nominal (>18year) & incomedependent (via employer) HC allowance HC allowance

Yvonne van Kemenade 1. HCI Act: consumer Free choice insurer: Free choice insurer: Premium - qualityPremium - quality choice of HC provider (contracted)choice of HC provider (contracted) Policy types: Restitution/ Benefit in kindPolicy types: Restitution/ Benefit in kind No claimNo claim Open enrollmentOpen enrollment Additional benefit packageAdditional benefit package Free to change yearlyFree to change yearly

Yvonne van Kemenade 1. HCI Act Changes insurers Mutual competition insurers Mutual competition insurers Private insurers, nationwide Private insurers, nationwide Acceptation obliged for basic p. Acceptation obliged for basic p. Responsible to provide care Responsible to provide care Differentiation on premiums forbidden Differentiation on premiums forbidden Risk adjustment Risk adjustment Freedom of contracting: negotiation HC providers Freedom of contracting: negotiation HC providers

Yvonne van Kemenade 1. HCA Changes insurer Policies: (not) contracted Policies: (not) contracted Attract/to hold on insured Attract/to hold on insured Having own organisations of HC Having own organisations of HC Group insurance (collectivities) Group insurance (collectivities) More competition - merges/ colloboration (HC authority) More competition - merges/ colloboration (HC authority)

Yvonne van Kemenade 2. Law on changing contracting (Wet HOZ) Abolish standard contract conditions Abolish standard contract conditions Red. restrictions foreign HC providers Red. restrictions foreign HC providers Free contracting insurers & organisations Free contracting insurers & organisations HCI A/ZFW: Restitution (no contract- obligation & no WTG) HCI A/ZFW: Restitution (no contract- obligation & no WTG)

Yvonne van Kemenade 3. HC Tariff Act Express (WTG Expres) Experiments possible Experiments possible Facilitating DRG’s Facilitating DRG’s Reducing bureaucracy & < administrative processes/costs Reducing bureaucracy & < administrative processes/costs Reduce Fraud Reduce Fraud

Yvonne van Kemenade 4. Law on hospital entitlement/facility (WTZi) 2 year sector-policy 2 year sector-policy Regiovision Regiovision Deregulate planning and building (& incl DRG) Deregulate planning and building (& incl DRG) Possibility for profit Possibility for profit Transparancy conditions Transparancy conditions

Yvonne van Kemenade 5. HC market regulation Act (WMG) ZAio/CTG: sector supervision ZAio/CTG: sector supervision (ZVW &AWBZ, not WMO) Include WTG Include WTG Stimulate competition Stimulate competition - (not) free prices - benchmark competition - regulating contract-conditions Fair competition: obuse position of power Fair competition: obuse position of power Monitoring Monitoring

Yvonne van Kemenade Regulation Authority (hospitals) 2005/ / Excessive tarriffs - Market force – obuse - Cross-subsidising - Stimulating transparancy - Informal sanctions

Yvonne van Kemenade First experiences (June 2006) Consumer mobility 20-25% Consumer mobility 20-25% Most mobility: group contracting Most mobility: group contracting Merger insurers: 4 insurers 90% market Merger insurers: 4 insurers 90% market Uninsured: ? Uninsured: ? Market orientation Market orientation

Yvonne van Kemenade Parties (insurers and hospitals/ specialists, consumers) are positioning Parties (insurers and hospitals/ specialists, consumers) are positioning Contracting Costs & Quality? Contracting Costs & Quality? Selective contracting? Selective contracting? Insurer as provider... Insurer as provider...

Yvonne van Kemenade Albert Schweitzer hospital The mergers Jacobus 1989 Refaja 1958 Municipal Hospital Dordrecht 1957 Municipal Hospital Sliedrecht 1957 Drechtsteden Hospital 1995 Merwede Hospital 1986 Albert Schweitzer Hospital 1999

Yvonne van Kemenade ASZ hospital Revenues: 185 million euro Revenues: 185 million euro Adherence: people Adherence: people employees employees 200 medical specialists 200 medical specialists 85 physicians in training 85 physicians in training No. of operational bed 700 No. of operational bed 700 One hospital: 4 locations One hospital: 4 locations Close to Rotterdam (20 km) Close to Rotterdam (20 km)

Yvonne van Kemenade Organisation chart Unique dual management Unique dual management

Yvonne van Kemenade Policy ASz hospital Costs/revenues (DBC’s/DRG’s 10% free) Costs/revenues (DBC’s/DRG’s 10% free) Positioning HC market (competition or colloberation): horizontal/vertical Positioning HC market (competition or colloberation): horizontal/vertical Teaching hospital: Partnerships with AMC, Erasmus MC and University of Utrecht Deregulation: threats but also more possibilities innovations etc.. Deregulation: threats but also more possibilities innovations etc..

Yvonne van Kemenade Strategic orientation (external markt, developments, prognoses, new providers, etc… marketing intelligence) and anticipating Strategic orientation (external markt, developments, prognoses, new providers, etc… marketing intelligence) and anticipating Strategic choices (functions, costs..) Strategic choices (functions, costs..) Surplus value/Right to excist Surplus value/Right to excist

Yvonne van Kemenade Client-awareness (who are our clients, what choices do they make and what influences that choices ect…) Client-awareness (who are our clients, what choices do they make and what influences that choices ect…) Health care governance: Health care governance: professionalise supervision of hospitals

Yvonne van Kemenade Trends/uncertainties??? Transparancy: Indicators HC prestations (benchmarks year ) Annual report Transparancy: Indicators HC prestations (benchmarks year ) Annual report (Selective) contracting ? (Selective) contracting ? Run some risk Run some risk Client awareness and choice ? Client awareness and choice ? Competition ? (effectiveness, quality, efficiency) Competition ? (effectiveness, quality, efficiency) Marketforces and power parties?? Marketforces and power parties??

Yvonne van Kemenade Conclusion-1 The insurer … The insurer … The hospitals… The hospitals… The consumers… The consumers… Much uncertainties, but also a lot of oppertunities… Much uncertainties, but also a lot of oppertunities…

Yvonne van Kemenade Reforms European countries (Basic principles) Costs control GDP % (expanding demand) Costs control GDP % (expanding demand) Changing finance systems hospitals, physicians, pharmaceuticals, medical devices etc. Changing finance systems hospitals, physicians, pharmaceuticals, medical devices etc. More cost sharing, out of pocket payments More cost sharing, out of pocket payments Emphasis on efficiency en effectiveness Emphasis on efficiency en effectiveness Priority on ambulatory care Priority on ambulatory care

Yvonne van Kemenade European countries, trends Technology assessment, admission requirements devices etc. Technology assessment, admission requirements devices etc. Transparency Transparency Invest in health data systems Invest in health data systems Monitor performance, using valid indicators and data and benchmarks Monitor performance, using valid indicators and data and benchmarks

Yvonne van Kemenade Conclusion-2 Health care in the Netherlands is moving towards a regulated market. The reforms and trends have the same basic principles as other European countries. But each country makes its own decisions because of differences in values, traditions, institutions. In the Netherlands, there is a lot to do the coming years and there are many uncerntainties….. …..But also a lot of oppertunities..

Yvonne van Kemenade