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Johan van Manen, Netherlands Healthcare Authority

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Johan van Manen, Netherlands Healthcare Authority

  1. 1. Commissioning health care under the Health insurance act West North West Hospital group conference, October 9th, Westport Johan van Manen Netherlands Health care authority
  2. 2. 2 Distribution of hospital services in the Netherlands • 131 hospital locations • 106 locations with facilities for outpatients
  3. 3. 3 Number of providers 2013 General hospitals 82 UMC 8 Independent Focus clinics 268 Annual spending on hospital care 2014 Hospitals 18.300 mln. € Specialists’ fees 2.200 mln. €
  4. 4. Health insurance companies 4 Total: 9 health care insurance groups, 26 labels
  5. 5. Health care providers Health insurance Financing HIA Risk adjustment fund State budget/Tax Office Households Health authority 1 2 3 4 5 6 7 8 9 10 1 income dependent premiums 2 subsidies 3 nominal premiums + deductible 4 payments into risk adjustment fund 5 risk equalisation health insurers 6 payments for contract / health care services 7 directives for services of general economic interest 8 compensations for services of general economic interest through Health Care institute 9 charges for exceeding MoH budget 10 health care services delivered to patients
  6. 6. Responsibilities in health care act
  7. 7. Basic characteristics 1. Health insurance: - After 2006, HI no longer required to contract all providers - diminishing ex post compensations in risk adjustment scheme HI - In theory unlimited care on individual level (within basic coverage) 1. Regulatory changes: - Gradual price liberalization since 2005, hospital budgeting system abolished in 2013 - Hospital care has over 70% free pricing - Decentralization of investment planning - Providers bear risk on exploitation of infrastructure - Influence of HI on capacity and distribution - In 2012, introduction of services of general (economic) interest in health care - Fundamental changes in tariff system (DBC) in 2012 - Collective bargaining (HI) banned under competition law
  8. 8. Recent changes in commissioning 1. In commissioning care HI apply minimum requirements as to number of procedures performed, number of patients treated etc. 2. Small hospitals face problems meeting requirements, forcing them to close down services, or seek cooperation with other providers. - Full service small hospitals will probably not survive as independent providers - Tendency towards mergers and / or larger hospital organisations 1. Standards are not imposed by MoH, HI can use self developed standards - Exception: emergency service must be accessible within 45 minutes for every inhabitant 1. HI plans to reduce number of emergency services shelved by order of the competition authority (ACM) 2. Commitment to finish annual contracting cycle (t+1) in november (t) 8
  9. 9. Financial issues and MoH intervention 1. In 2011, MOH reached agreement with national health care associations to limit growth in expenditure (2012-2017). Annual growth 1% - Legislation enabling across the board cuts in revenue 1. Immediate effect on commissioning and contract negotiations - Agreement serves as guideline 1. Reduction in both growth in expenditure and HI premiums 9
  10. 10. Expected changes in near future 1. For 2015 a number of changes are expected: - Hospitals will be allowed to change into ‘for profit’organisations - A rise in premiums + deductible - Change in Health insurance act: consumers loose right to reimbursement for care by non- contract provider - Further extension of covered package - Formerly long term care brought under HIA 1. VGZ announces changes in commissioning policy, hospitals with below average performance will loose contracts 10
  11. 11. Lessons learned (1) 1. Rising premiums and rising HI’s profits are a sensitive issue with public and politicians alike 2. Nominal premiums are kept in check by competition so far - But: we don’t know if without the MoH intervention, rise in expenditure would have been curbed 1. Little discussion about the system as such but HI premiums are means of income policy and often cause for political debate 2. In hospital care, ‘selective contracting’ still only in infant stage 3. Although HI claim to emphasize quality aspects in commissioning, hospitals complain that across the board price cuts and lumpsum contracting are standard practice 4. 2012 changes in tariff system, combined with other changes in system proved too complex to handle 11
  12. 12. Lessons learned (2) 1. There is some concern about the growing power and influence of the health insurers. - Monopsony in some regions? 1. Both sellers and buyers show tendency towards concentration - In some regions, (very) limited choice in providers - Cause for concern: hospitals and insurers becoming ‘too big too fail’ - Threat to stability of the system 1. Discussion and compromise on right to choose one’s provider/ physician: - Restrictive contracting will not apply to GPs 1. Signs of strain: - Re-occurrence of waiting lists: - 1 highly specialised provider put new patients on waiting list - 2 hospitals limited access for HI’s clients, due to contract issues 12
  13. 13. Overall conclusions on commissioning 1. Lack of long term MoH view on capacity and / or regional distribution - Only minimum standards and broad/global standards on commissioning / required level of care 1. Maintaining adequate level of services by HI could be problematic in some areas 2. At the same time, MoH intervenes at every level imaginable, only by way of informal procedures and agreements 3. Agreements on national level are counterproductive to ‘real’ competition 4. Concentration in the market leads to mutual dependency of HI and hospitals: both try to avoid risk / loosing market share 5. Disappearance of small providers causes lack of choice - Little distinction between HI 13
  14. 14. 14 Thank you for your attention! Contact: Johan van Manen NZa Postbus (Po box) 3017 3502 GA Utrecht (NL) E: jmanen@nza.nl

Notas do Editor

  • Map showing hospital locations
    Total population 16,5 mln.
  • Total expenditures under HIA for hospital services (excluding psychiatric care)
  • Share in # insured
  • Financing healthcare under HIA
    Complex financing scheme, where nearly all procurement/commissioning is responsibility of health insurers
    Payments for (health care) services of general economic interest cover e.q. emergency services (remote areas), helicopter EMS, on the job medical training etc. ca. 10% of total acute hospital expenditure
    MoH and NL Health care institute responsible for risk adjustmentscheme and payments
  • Table shows the responsibilities of several actors within the health care system.
    MoH is relinquishing role in planning; decentralisation of investment decisions and health care procurement
    National budget: BKZ (Budgetary framework health care)
  • 2012 changes in dbc system, combined with the end of the hospital budgeting system, had far reaching consequences.
    An elaborate transitory model was introduced for the years 2012/2013 , which in combination with other measures caused problems because of it’s complexity.
    The changes in the tariff system also led to investigations into alleged fraudulous billing. HI have intensified control measures under pressure of Health authority
    Because of this, we expect problems with hospitals’ annual financial reports until the end of 2014
  • 2) example: OZG and UMCG; concentration of services on new central location, financing difficult, probable takeover by university hospital
    Cumulation of changes in 2012/2013 led to protracted price & contract negotiations. To further transparancy towards consumers (who can switch HI at the end of every year) HI and hospitals agreed to
    have contracts ready by november
  • Agreed growth rate: 1,5% in 2014, 1% from 2015-2017
    For 2015, another rise in premium and deductible is expected (premiums + 120, deductible +15 (360=>375)
  • Changes in HIA led to dispute on freedom to choose personal physician. From 2015, HI’s choice is leading; this does not apply to GPs and other primary care.
  • Report on formal evaluation HIA, requested by MoH, published end of september (mandatory evaluation every 5 years)
    Most important conclusions on commissioning:
    Increasing competition between HI caused by abolishing the representation model (where 1 HI woudl negotiate on behalf of other HI)
    Increasing risk/ incentive for HI, caused by changes in ex post risk adjustment
    Influence of MoH agreements
    Increase of free pricing
    Increasing use of quality indices, but worrying lack of transparancy in providers’ quality especially towards consumers. Growing burocracy instead.
    Frequent and late changes in government policy have negative influence on contracting process.
    Mergers and concentration of providers