|HI Reforms 1987-2003|
|Implemented in this survey?|
The introduction of Diagnose and Treatment Combinations (DTCs) is an instrument of regulated competition in Dutch health care. Adequate product-information and classification is a precondition for regulated competition among insurers and providers. To facilitate DTCs, it is necessary to review and reform several laws. In May 2003, an experiment started. For 17 DTC groups, insurers were allowed to negotiate about price, volume and quality of care with providers.
The introduction of Diagnose and Treatment Combinations is an instrument to support the implementation of regulated competition in Dutch health care. Adequate product-information and classification is a precondition for regulated competition among insurers and providers. Diagnose and Treatment Combinations (DTC) are almost similar to Diagnose Related Groups. However, Diagnose and Treatment Combinations also contain the clinical aspects and day-care in the treatment of a patient, whereas Diagnose Related Groups don't. Diagnose and Treatment Combinations affect health insurance companies and health care providers the most. They should negotiate about prices, volume and quality of care. To make Diagnose and Treatment Combinations possible it is necessary to review and reform several laws.
|Medienpräsenz||sehr gering||sehr hoch|
The development of DTC has to be understood against the background of making the Dutch health care system more competitive. Ultimate goals has been, and still is, to meet the competing goals
of an efficient, equitable and universally accessible health care system. Already in 1987, the independent Dekker-committee proposed a mandatory national health insurance scheme in order to guarantee
universal access to 'basic' health care services, while regulated competition should create incentives for both insurers and providers to improve the efficiency of health care delivery. See for this
the report on "The attempts to introduce a national health insurance scheme with managed or regulated competition among insurers and providers.", reported in the first round of the Health Policy
A major change of these reforms has been is, and till is, the replacement of the hospital budgeting system and the lump sum funding of medical specialists by a payment system based on about 400 to 600 Diagnosis and Treatment Combinations (DBCs). After several years of preparation, the new system was expected to come into force in 2004.
Since 1982, the Health Care Prices Act (WTG) is in force, regulating the prices of health care services. According to this law, prices of health care services have to be negotiated by the formally recognized representative organizations of health care providers and health insurers and are subject to the approval of the Council on Health Care Prices (CTG). The government is entitled to give binding instructions to the CTG. Within the WTG, however, individual insurers and providers are not allowed to negotiate prices and volume of services. Nor are there any selective contracts possible within the WTG. The sickness fund scheme (ZFW), regulating the social health insurers, also forbids selective contracting. Both laws have to be adjusted in order to make DTC possible.
|Implemented in this survey?|
Regulated Competition among insurers and providers was introduced in the reformplan of the Dekker-committee in 1987. What happened to these proposals reveals at first sight how limited the scope
for path breaking reforms in Dutch health care in fact is. From the Dekker plan until today, comprehensive reform efforts seem to have been so misshapen during the course of their implementation that
their effectiveness must be seriously questioned. But at a closer look, important incremental changes were implemented enhancing the institutional and technical feasibility of regulated competition.
Eventually, in the government's most recent health reform proposal (Ministry of Health, 2001) the Dekker plan has risen from its Phoenix ashes. Moreover, due to the instrumental and
institutional adjustments that took place during the last decade, the prospects of today's market-oriented reform policies are much better than at the beginning of the nineties.
Insurers should have the possibility of individual negotiations with healthcare providers. These individual contracts are part of the Diagnose and Treatment Combinations (DTC).
The new liberal minister of Health (Mr. Hoogervorst) claimed that Diagnose and Treatment Combinations should be implemented by January 2004. When it turned out that the introduction of DTC's is very complex, Hoogervorst proposed a more gradual introduction of the DTC's. In July 2004 insurers are expected to negotiate with healthcare providers about price, volume and quality of care. These negotiations are limited till 10% of the total hospital budget. In 2005 further steps will be taken to a more performance-oriented payment system. The present system of budgets should then be history. Also the space for negotiations and selective contracting should than have become larger.
In May of this year, an experiment started. For 17 groups of Diagnose and Treatment Combinations insurance companies were already allowed to negotiate about price, volume and quality of care with the health care providers. For all of these 17 groups there was an extremely high waiting list. It was expected that hospitals and insurers would do anything to contract as many care as they can.
The first reaction of the providers was very defensive. According to them, more competition in healthcare should lead to less quality of care and extremely high costs. Insurers, on the other hand, were quite positive. They will become more responsible for the purchase of care and for the account of costs. Potential disadvantage for insurers is the growing competition among health insurers.
§ There is no new law developed for the introduction of DTC. Instead, pre-existing legislation (WTG and ZFW) has to be adjusted in order to make DTC compulsory. Especially the WTG (Health Care Prices Act) will have to be much more flexible in order to make the introduction and development of DTC possible. Next to this, it is necessary:
At the beginning, health care providers and medical specialists were very reluctant. Medical-specialists refused to cooperate with respect to the registrations, necessary for the development of Diagnose and Treatment Combinations. However, with the idea of Diagnose and Treatment Combinations has become more accepted now. Although the refusal to cooperate on registration is sometimes used as a weapon in other conflicts by medical-specialists. Health insurers are more positive about DTC's and regulated competition. The government sees the introduction of DTC's as a necessary precondition for regulated competition, since DTC could enhance the efficiency and transparency of health care providers.
See above on Experiments. It is now widely accepted that experiments with DTC and evaluation of these experiments are necessary for the further development and improvement of DTC's. Moreover, experiments could also improve the acceptance of, and commitment to, involved actors.
|Qualität||kaum Einfluss||starker Einfluss|
|Gerechtigkeit||System weniger gerecht||System gerechter|
|Kosteneffizienz||sehr gering||sehr hoch|
Magazines: Zorgvisie, ZM-Magazine
Several political and policy documents from the Ministry of Health and the Dutch Parliament http://www.opmaat.nl
(all in Dutch)
|HI Reforms 1987-2003|
Process Stages: Umsetzung, Evaluation, Strategiepapier, Gesetzgebung, Idee, Pilotprojekt, Veränderung/Richtungswechsel
Jan-Kees Helderman, Anniek Peelen_(Institute of Health Policy and Management, Erasmus Medical Centre, Erasmus University Rotterdam