Inzicht in de wereld van de zorgverzekeraar

1
A new hospital care financing system based on
health care products the health insurer
perspective
2
Agenda

• Motivation reforms
• Starting points
• Development
• Implementation
• Related issues

3
Hospital finance reforms, motive 1Problems with
current financing system

• Supply driven doesnt motivate production
• Too much bureaucracy, obstruction of initiatives
• Undesired incentives in the current financing
  system
• No transparency value for money?
• No incentive for efficiency
• Only weak relation between actual costs and
  budget
• Unfunded differences in income medical doctors

4
Hospital finance reforms motive 2 Changing roles
and responsibilities

• Withdrawing government
• Change from supply to demand driven health care
• Performance based payment
• Competition between suppliers
• Competition between insurers
• Transparency
• Realistic price development

5
Point of interest new financing system

1. Demand driven, control focused on content of
   health care
2. Contracts concerning content of health care (no
   roughly defined parameters as number of
   outpatient clinics)
3. Costs of care are directly linked to the
   expenditures of care
4. Transparency and responsibility are essential

6
Cause for change

• System was successful in terms of macro cost
  containment
• But waiting lists and low innovation and
  micro efficiency
• More money went into the current system..
• Health expenditure 14 BBP in 2040
• (22 labour force working in health care in 2025

7
Necessary shift of responsibilities

• Less price and capacity regulation
• More incentives for insured and insurers to
  control costs
• More instruments for insured and insurers to
  demand better value for money
• More competition between insurers and providers
• Improved market regulation

8
Summarised Main goals of hospital finance
reforms

• Transparancy
• Performance based payment
• Competition

9
Dutch health insurance system

• Dual system Publicly funded and private health
  insurances
• Health insurance budgeting based on
  characteristics insurer population
• Health insurer specific nominal premium
  (competition)
• Increasing responsibility, health care
  director, translated in e.g. more financial
  risks
• Coming reforms for 2006 merge public and private
  health insurance

10
Health Insurance Companies
Insured person can choose and switch - premium-
quality- content of contracts
NEED FOR INFORMATION PATIENT EMPOWERMENT
11
To compete health insurers have to contract
sufficient care of good quality for a reasonable
price.
Health InsuranceCompany
Need for transparency in performance
Instruments to determine the value for money
Negotiations on volume, price and quality
12
Former and current functional Budget

• Based on
• fixed parameters (e.g. buildings)
• semi-variable parameters (e.g. number of beds,
  medical doctors)
• variable parameters (e.g. number of outpatient
  clinics, number of day care treatments, hospital
  days)

13
DBCs

• Patient classification system
• DBC Diagnosis Treatment Combination
• Uniform defined health product/ process
  description
• Description of the total health path

14
Example of a DBC Knee surgery
15
Summary of unique aspects DBCs

• Episode management / medical process description
• DBCs are applicable for all hospital activities
  (including outpatient and daycare)
• DBCs include the remuneration of medical
  specialists
• Registration during the health care process

16
Spin Off DBCs

• Incentive for improvement of efficiency
• Vehicle for benchmarking
• Starting point for quality policy development
• Provide insight in capacity requirements
• Provide new control information
• Starting point for financing of integrated care
• Enabler for the Electronic Patient File

17
DBC development in the Netherlands

• Started slowly in mid 90s
• Initiated by providers and insurers
• Adopted by government in 2000
• Steering committee with all relevant parties
• ICT development financially stimulated

18
Phases DBC implementation

• Phase 1 DBC experiment
• Phase 2 DBC implementation
• Phase 3 Full introduction of market principles

19
Phase 1DBC Experiment (2003 - 2004)

• Implementation of a limited set of DBCs
• Characteristics simple, waiting list and labour
  related
• Free negotiations on price, volume and quality
• Voluntary participation
• Objectives
• Incentives for production?
• Ability of insurers to realise good contracts
  (good care/sharp prices)?
• Lessons for market parties?

20
Phase 2 DBC implementation (2005-2006)

• Two segments
• Segment A 90 fixed DBC prices
• Segment B 10 free DBC prices
• Budgeting based on existing parameters
• Financing based on DBCs
• Including remuneration medical specialists

21
Phase 3 Full introduction of market
principles(2007 - )

• Budgeting Financing
• Local/individual DBC agreements
• Free negotiations
• Reallocation between hospitals

22
Preconditions phase 3

• All hospital costs integral part of the DBC
  prices or incorporated in separate budgets
• Sector specific market authority
• Proper relation with the insurer budgeting model
• Full risk for insurers
• Sufficient competition between providers
• Free entry to the market
• Market transparency
• Level playing field

23
DBC related issues

• Academic care, acute care, education, patient
  medication, capital costs (interest,
  depreciation)
• Privacy
• Fraud validation module, administrative
  procedures
• DIS DBC information system
• Control of total hospital care expenditures

24
DBC impact health insurer

• Enormous administrative operation
• Rebuilding benchmark information
• Delay in declaration (structural and
  non-structural)
• New fraud possibilities
• Relatively low market power (scarcity Dutch
  market)
• Guiding possibilities (soft versus hard)