Health(care)
in the Netherlands
Health~Holland Visitors Programme 2018
Workshop
09:00 Welcome by ModeratorPeter Post, Director, Task Force Health Care
09:05 Welcome & OpeningErik Gerritsen, Secretary-General, Ministry of Health, Welfare & Sport
09:15 The Dutch Health(care) System: Accessibility,
Quality & AffordabilityProf. Patrick Jeurissen, Chief Research Scientist,
Ministry of Health, Welfare & Sport
10:15 Coffee Break
10:45 Parallel Sessions
Value-Based Health Care | eHealth | Elderly Care
12:00 Networking Lunch
Innovation Climate & PPPs for Innovation in Health (15 min)
By Prof. dr. Nico van Meeteren, Executive Director, Health~Holland
13:00 End
Agenda
Warm welcome!热烈欢迎
Bienvenido
Velkommen
Herzliches Willkommen Selamat datang
Tervetuloa
Välkommen
ласкаво просимо Bem-vindo
Bienvenue
गर्मजोशी से स्वागत
Karibu sana ಸ್ವಾ ಗತ
09:00 Welcome by ModeratorPeter Post, Director, Task Force Health Care
09:05 Welcome & OpeningErik Gerritsen, Secretary-General, Ministry of Health, Welfare & Sport
09:15 The Dutch Health(care) System: Accessibility,
Quality & AffordabilityProf. Patrick Jeurissen, Chief Research Scientist,
Ministry of Health, Welfare & Sport
10:15 Coffee Break
10:45 Parallel Sessions
Value-Based Health Care | eHealth | Elderly Care
12:00 Networking Lunch
Innovation Climate & PPPs for Innovation in Health (15 min)
By Prof. dr. Nico van Meeteren, Executive Director, Health~Holland
13:00 End
Agenda
Going Dutch? If “context”
is not transferrable what
remains?
Prof. dr. Patrick Jeurissen
The Netherlands: average crude health(Healthy) live expectancy Female smokers
NL
SE
IT
0 50 100 150 200
SwedenMalta
CyprusItaly
PortugalIreland
LuxembourgSpain
United KingdomNetherlands
FinlandFrance
GermanyAustria
DenmarkEU average
GreeceBelgium
Czech RepublicLatvia
SloveniaEstonia
BulgariaSlovakia
LithuaniaPolandCroatia
RomaniaHungary
2000
2015
Preventable mortality
Preventable hospitalizations
Age standardized rates per 100.000 population
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: pro-cyclical (% GDP)Health expenses OECD 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
0
1
2
3
4
5
6
7
8
9
10% GDP
LTC expenditure projection 2013 - 2060
Bridging equity and efficiency? Going Dutch? Regulated competition 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 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 (2015): inpatient, outpatient, community
Cost control 2012 – 2018: so far so good, is it safe?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
The why of successful cost control
Less growth in health expenses (2012 – 2018)
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 enrolees
′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
Declining numbers of patients/clients on a low baseline
2008 2009 2010 2011 2012 2013
outpatient 405 400 403 408 384 393
inpatient/daycare 226 239 251 265 268 246
remaining hospital 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)Per capita expenses pharmaceuticals
Active purchasing? Few changes in provider market shares (MVI)
0,0%
2,0%
4,0%
6,0%
8,0%
10,0%
12,0%
14,0%
16,0%
2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13 2013/14
hospital care
elderly care
disability care
municipal care
personal budgets
-1
-0,8
-0,6
-0,4
-0,2
0
0,2
0,4
0,6
0,8
1
-0,6% -0,4% -0,2% 0,0% 0,2% 0,4% 0,6%
chan
ge in
co
ntr
acte
d c
are
Change in market share
Active purchasing in-vitro fertilization?
0%5%
10%15%20%25%30%35%40%45%50%
Success rates (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 -2018)
• Responsiveness to changes: reforms alter mental models
• Lower volumes in an aging society, a need for careful watching
• Efficiency: steering on best-practices
• Aligning trends in epidemiology/technology with budgetary policy
• Do not disturb intrinsic motivation by professionals
• Do not put all your cards on active purchasing
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 behaviours3) To build ‘resilience’: solvency, capital investments, workforce
Thank you for your attention
09:00 Welcome by ModeratorPeter Post, Director, Task Force Health Care
09:05 Welcome & OpeningErik Gerritsen, Secretary-General, Ministry of Health, Welfare & Sport
09:15 The Dutch Health(care) System: Accessibility,
Quality & AffordabilityProf. Patrick Jeurissen, Chief Research Scientist,
Ministry of Health, Welfare & Sport
10:15 Coffee Break
10:45 Parallel Sessions
Value-Based Health Care | eHealth | Elderly Care
12:00 Networking Lunch
Innovation Climate & PPPs for Innovation in Health (15 min)
By Prof. dr. Nico van Meeteren, Executive Director, Health~Holland
13:00 End
Agenda
10:45 Parallel Sessions
Value-Based Health Care eHealth Elderly Care
Outcome-based healthcareDimitri Schakelaar, Program manager Outcome based healthcare, Ministry of Health, Welfare & Sport
Learning CoalitionsPaul Boon, Project lead for ‘Learning coalitions’, National Health Care Institute
eHealth Policy
By Ron Roozendaal, Director of Health
Information Policy & Chief Information Officer,
Ministry of Health, Welfare & Sport
Elderly Care Policy
Martin Holling, Ministry of Health, Welfare &
Sport
Evidence-based solutions for Ageing Society
Prof. Dr. Robbert Huijsman, Erasmus School of
Health Policy & Management
12:00 Networking Lunch
Innovation Climate & PPPs for Innovation in Health (15 min)By Prof. dr. Nico van Meeteren, Executive Director, Health~Holland
13:00 Transfer to Field Visits
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Thank you!
Lets have some coffee