Diagnose and Treatment Combinations

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

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.

Purpose of health policy or idea

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.

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

Political and economic background

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 Monitor.

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.

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

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.

Stakeholder positions

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. 

Influences in policy making and legislation

§         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:

1. Develop a national system of performance and product classification that is not dependent upon the approval of the Council on Health Care Prices (CTG).
2. To develop DTC's that may be subject to more than one CTG guideline, dependent on the types of care that are covered by the specific DTC.
3. To develop legislation which combines a system of product- and performance classification and negotiations about prices between insurers and providers.
4. To develop legislations for experimenting with DTC's.
5. To adjust the Sickness Fund Scheme order to make selective contracting possible.
6. To develop legislation that protects the privacy of individual patients.

Adoption and implementation

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.

Monitoring and evaluation

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.

Expected outcome

• The introduction of a complex system like Diagnose and Treatment Combinations necessarily takes a long time. At first, Diagnose and Treatment Combinations should be fully operational in January 2004. Now it is postponed to 2005.
• By this time, an experiment is running. Some effects are already visible. It makes clear that negotiations between insurers and providers take a long time and that medical-specialists are having troubles with there fees.
• Access to healthcare should be enlarged. If the system becomes more efficient, more patients can be treated.
• The aim is to get a more efficient and transparent health care system.

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch

References

Sources of Information

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)

Reform formerly reported in

HI Reforms 1987-2003 Process Stages: Umsetzung, Evaluation, Strategiepapier, Gesetzgebung, Idee, Pilotprojekt, Veränderung/Richtungswechsel

Author/s and/or contributors to this survey

Jan-Kees Helderman, Anniek Peelen_(Institute of Health Policy and Management, Erasmus Medical Centre, Erasmus University Rotterdam

Empfohlene Zitierweise für diesen Online-Artikel:

Jan-Kees Helderman, Anniek Peelen_(Institute of Health Policy and Management, Erasmus Medical Centre, Erasmus University Rotterdam. "Diagnose and Treatment Combinations". Health Policy Monitor, December 2003. Available at http://www.hpm.org/survey/nl/b1/1