1. Dutch Orthopaedic Surgery Introduction of the country and the specialty

2. The Netherlands On Saturday 13th of October: 16.385.486 inhabitants, 484 / km2 On Saturday 13th of October: 16.385.486 inhabitants, 484 / km2 Growing with average 80 persons per day, birth 515, death 375, net immigration -75 Growing with average 80 persons per day, birth 515, death 375, net immigration -75 Contact family doctor per year 75% - 72% Contact family doctor per year 75% - 72% Contact specialist per year 37% - 40% Contact specialist per year 37% - 40% 2007-10-19 Frank van Oosterhout, UEMS, Toulouse 20072

3. 2007-10-19 Frank van Oosterhout, UEMS, Toulouse 20073 Age and mix of population “Green demographic pressure” lowered from 68% to 40 % (ages 0 -20 / 20-65) “Green demographic pressure” lowered from 68% to 40 % (ages 0 -20 / 20-65) “Grey demographic pressure” rose from 14 % to 24 % (ages over 65 / 20-65) “Grey demographic pressure” rose from 14 % to 24 % (ages over 65 / 20-65) Immigrants, “non Dutch”, all generations, 3.170.406 is 19 % of the population Immigrants, “non Dutch”, all generations, 3.170.406 is 19 % of the population

4. 2007-10-19 Frank van Oosterhout, UEMS, Toulouse 20074 Number of Hospitals 8 University Hospitals 8 University Hospitals 88 General Hospitals 88 General Hospitals 9 Specialised Hospitals 9 Specialised Hospitals 51.000 hospital beds incl. day-care 51.000 hospital beds incl. day-care 247.000 employees excl. private practice medical specialists 247.000 employees excl. private practice medical specialists 7000 medical specialist in private practice 7000 medical specialist in private practice

5. 2007-10-19 Frank van Oosterhout, UEMS, Toulouse 20075 Risk Management On 1st January 2008 all Dutch hospitals must have a risk management system, not only on medical risks but also on general risks for example fire risks, even financial risks and a system of blame free reporting On 1st January 2008 all Dutch hospitals must have a risk management system, not only on medical risks but also on general risks for example fire risks, even financial risks and a system of blame free reporting Corporate governance becomes for hospitals as usual as it is for companies Corporate governance becomes for hospitals as usual as it is for companies

6. 2007-10-19 Frank van Oosterhout, UEMS, Toulouse 20076 Orthopaedic surgery Dutch Orthopaedic Association Dutch Orthopaedic Association 770 members, 470 active surgeons, 3 non member orthopaedic surgeons. 770 members, 470 active surgeons, 3 non member orthopaedic surgeons. 3 general meetings each year, 2 of two days and 1 of one day 3 general meetings each year, 2 of two days and 1 of one day Main meeting every year in another city, main topic, sometimes together with neurosurgeons, plastic surgeons or traumatologists Main meeting every year in another city, main topic, sometimes together with neurosurgeons, plastic surgeons or traumatologists

7. 2007-10-19 Frank van Oosterhout, UEMS, Toulouse 20077 Dutch Orthopaedic Ass. (1) DOA (NOV) is full member of the NOF DOA (NOV) is full member of the NOF DOA-BVOT meeting every two year DOA-BVOT meeting every two year DOA full member of B&J Decade DOA full member of B&J Decade DOA and subspecialty groups on traumatology, pediatrics, implants, arthroscopy, spinal, foot - ankle and shoulder - elbow DOA and subspecialty groups on traumatology, pediatrics, implants, arthroscopy, spinal, foot - ankle and shoulder - elbow

8. 2007-10-19 Frank van Oosterhout, UEMS, Toulouse 20078 Dutch Orthopaedic Ass. (2) Working groups on training and education Working groups on training and education Working group on scientific work Working group on scientific work Working group on disability evaluation Working group on disability evaluation Working group on business aspects Working group on business aspects Working groups on patient education, communication, website, professional and product quality. Working groups on patient education, communication, website, professional and product quality.

9. 2007-10-19 Frank van Oosterhout, UEMS, Toulouse 20079 Working Environment Private practice 65 %, employee 32 % Private practice 65 %, employee 32 % General hosp. 46 %, training hosp. 29 % General hosp. 46 %, training hosp. 29 % University hosp. 18 %, University hosp. 18 %, One specialised hospital with 13 OS One specialised hospital with 13 OS Several private clinics Several private clinics 87 % calls itself fulltime with 52.2 as a mean number of working hours / week 87 % calls itself fulltime with 52.2 as a mean number of working hours / week

10. 2007-10-19 Frank van Oosterhout, UEMS, Toulouse 200710 “Orthopaedic Performance” 220.000 operations, 224.000 admissions 220.000 operations, 224.000 admissions 34.500 meniscal excisions 34.500 meniscal excisions 19.400 knee implants 19.400 knee implants 22.400 total hip arthroplasties 22.400 total hip arthroplasties 2.300 spondylodeses 2.300 spondylodeses 10.600 intervertebral excisions 10.600 intervertebral excisions

11. 2007-10-19 Frank van Oosterhout, UEMS, Toulouse 200711 Professional Quality The D.O.A and its system of quality control The D.O.A and its system of quality control Peer to peer visits every five years, if needed more frequent Peer to peer visits every five years, if needed more frequent Report of the visit is confidential, the result is not Report of the visit is confidential, the result is not Quality visit is mandatory for continuation of individual registration as medical specialist Quality visit is mandatory for continuation of individual registration as medical specialist

12. 2007-10-19 Frank van Oosterhout, UEMS, Toulouse 200712 Product Quality (1) General Hospital Performance Indicators General Hospital Performance Indicators Indicators on system, process and few on outcome Indicators on system, process and few on outcome For orthopaedic surgery: time between admission and operation in hip fracture patients For orthopaedic surgery: time between admission and operation in hip fracture patients Also: systematic registration of complications Also: systematic registration of complications

13. 2007-10-19 Frank van Oosterhout, UEMS, Toulouse 200713 Product Quality (2) New indicators, especially on orthopaedic surgery, next year mandatory New indicators, especially on orthopaedic surgery, next year mandatory Insisted on by health insurance companies and patient organisations Insisted on by health insurance companies and patient organisations Complication registration, implant registration, DVT prophylaxis, infection prophylaxis, patient education for hip and knee surgery Complication registration, implant registration, DVT prophylaxis, infection prophylaxis, patient education for hip and knee surgery

14. 2007-10-19 Frank van Oosterhout, UEMS, Toulouse 200714 Implant Registration The Dutch Orthopaedic Implant register almost died ten years ago because of lack of financial air The Dutch Orthopaedic Implant register almost died ten years ago because of lack of financial air With the new DBC (=DRG look alike) system resuscitation started, money infusion With the new DBC (=DRG look alike) system resuscitation started, money infusion This year, 11 hospitals start over with a new system, developed by the Leiden University Orthopaedic Clinic This year, 11 hospitals start over with a new system, developed by the Leiden University Orthopaedic Clinic

15. 2007-10-19 Frank van Oosterhout, UEMS, Toulouse 200715 Healthcare finance (1) All inhabitants have a health care insurance All inhabitants have a health care insurance There are seven insurance companies in a competitive market There are seven insurance companies in a competitive market They all have to offer a basic insurance package for a standardised set of health care services, so they can only compete on price and company service They all have to offer a basic insurance package for a standardised set of health care services, so they can only compete on price and company service

16. 2007-10-19 Frank van Oosterhout, UEMS, Toulouse 200716 Healthcare finance (2) Private paractice orthopaedic surgeons are paid by fee for service in a DRG look alike system, called DBC Private paractice orthopaedic surgeons are paid by fee for service in a DRG look alike system, called DBC Hospitals are paid in a complicated budget system based on historical out clinic, clinic and day care production plus some other parameters Hospitals are paid in a complicated budget system based on historical out clinic, clinic and day care production plus some other parameters These two systems are not always compliant These two systems are not always compliant

17. 2007-10-19 Frank van Oosterhout, UEMS, Toulouse 200717 Healthcare finance (3) Not only the insurance companies but also the hospitals and medical specialists arrive in a competitive market with a government disappearing to a background role Not only the insurance companies but also the hospitals and medical specialists arrive in a competitive market with a government disappearing to a background role Within years hospitals will issue stocks and pay there investors, or will be bought and sold by investors Within years hospitals will issue stocks and pay there investors, or will be bought and sold by investors Will medical specialist become stockholders of the hospitals? Will medical specialist become stockholders of the hospitals?