1. Comments to „A“: „The health care system“ Arie Hasman & Achim Hochlehnert Health Care in the Information Society - on the Prognosis for the Year 2013 Workshop in Braunschweig, 21-22.5.2013

2. T1: Demand for health care services T1: Due to the changes in the structure and usage behavior of the population, the demand for health care services will continue to increase. P1.1: The share of health care costs will rise above 12% of the gross domestic product. => Costs in the Netherlands in 2011: 12%. In the Netherlands there was a structure change in 2006: more market driven, hospitals paid for products (via a kind of DRG). Resulted in lower prices and more efficient care but the financial advantages were cancelled by increasing volume. Care fraud. In 2012 5600 euro per capita, 12 years ago 2800 euro. In 2012 92 billion euros, costs almost doubled in 12 years. P1.2: The number of individuals employed in the health care sector will increase to over 13% of all employed in Germany. => In the Netherlands 1.4 million fte, 38% increase in 10 years. In Germany the number also increased.

3. T2: Higher share on outpatient care services T2: The basic structure of the health care sector (physician practices, hospitals, health insurance agencies, etc.) will, in essence, remain unchanged. However, due to rising costs, a higher share will fall on outpatient care services. P2.1: The number of inpatient beds will decrease by 20%. => In the Netherlands 12% overcapacity of beds, because of lower length of stay in hospitals; 22% day care. P2.2: The average length of stay for inpatient hospital care will decrease below 7 days. => Average length of stay in 2010: 5.8 days, when one-day treatment is included below 3 days. This is due to the fact that now treatments are remunerated and hospitals are not paid per day-of- stay.

4. T3: Importance of integrated alliances T3: The increase in costs and in patients’ quality awareness will strengthen the importance of integrated, cooperative alliances, e.g. between hospitals and physicians’ practices. These health care alliances will force the boundaries currently existing between in and out patient care further into the background. P3.1: Over 60% of all service providers will take part in cooperative alliances. => In Netherlands specialists can offer services outside of the hospital. But still the GP has to refer the patient. GP is gate keeper. P3.2: Over 80% of all patients will be treated within such alliances. => Not applicable in the Netherlands. There is a tendency to leave more to the GPs. In Germany less than 80 % of all patients are treated within a cooperative alliance (looking for data).

5. T4: Use of tele-medical methods (1) T4: Medical advances and increasing costs will fuel the formation of highly specialized care centers. The use of tele-medical methods for exchanging information will increase. However, the spread of such methods will depend on secure, attractive payment for such services. P4.1: At least 10% of severely ill patients, or those with complicated cases, will make use of tele-medical second opinion. => A second opinion is possible in the Netherlands without costs, but physicians want payment. Usually not via tele-medical methods. P4.2: Tele-therapy, in the sense of longdistance operations (tele- surgery), will, however, remain the exception and remain under the 10% mark. => Indeed.

6. T4: Use of tele-medical methods (2) P4.3: Tele-diagnostics and tele-therapy, in the sense of long-distance recommendations to local specialists in low population areas, in special situations (e.g. on see, in space, military assignments in crisis areas, etc.), and in cases of rare diseases, will increase so considerably that they will account for 50% of all health care measures. => Tele-diagnosis exists, for example for dermatological cases. Usually the distances are so small that costs of tele-diagnosis are larger than sending the patient to the specialist. Difficult to get figures.

7. T5: Importance of service provider quality T5: Due to the increase in costs, the question of service provider quality will become even more important. Therefore, accreditation guidelines will arise, allowing hospitals and health alliances to certify themselves. P5.1: Over 40% of the hospitals will be certified. => In the Netherlands the NIAZ (Dutch Institute for Accreditation in Care) has contracts with many hospitals, etc. Probably more than 40% of institutes. In Germany the number of certified hospitals increased as a consequence of the pressure by the service providers. P5.2: Ninetyfive percent of the service offers will be contained in indices available publicly over the Internet. => Hospitals have to deliver information about a number of performance indicators which are publicly available on the Internet.

8. T6: Different financial models (1) T6: Due to increasing costs, different financial models will become necessary. P6.1: Over 10% of the outpatient costs will be invoiced by using rates for diagnosis related groups. => In the Netherlands Diagnosis Treatment combinations (DBCs) are used for remuneration in hospitals and also for outpatient clinic treatment. In Germany outpatient costs are not invoiced by DRG-rates in Germany, but DRGs will be introduced into the psychiatric section in the upcoming years.

9. T6: Different financial models (2) P6.2: The private participation of patients in their own health care costs will increase. The share of these costs will increase over the 12% mark. => In the Netherlands premiums are paid for insurance. This is partly income dependent directly subtracted from the income (around 7% of an income up to 33.000 euros) and an amount of around 1300 euros to be paid directly to the insurance company. In addition they pay 1.5% of the healthcare costs themselves (2009).This year 320 euros have to be paid before the insurer remunerates. If nothing changes in 2020 the Dutch pay 25% of their income for healthcare. In Germany the private participation of patients also increased. There was a quartal participation 10 € for outpatients („Praxisgebühr“) since 2004 which was cancelled again in January 2013.