|Implemented in this survey?|
cost-effective home care
The main purpose of the Law on Social Support (which came into effect in 2006) is to make municipalities responsible for a set of health-related social services including family help (domestic care; e.g. housekeeping, simple supportive health services like bath help) which were previously covered under the Exceptional Medical Expenses Act (Algemene Wet Bijzondere Ziektekosten: AWBZ). The underlying idea is that municipalities are better capable than health insurers to manage family help services and to organise integrated care for the sick and the frail elderly at the local level.
Cost-effective (integrated) home care; main tools are decentralisation to municipalties and competitive bidding.
financial and non-financial (decentralisation)
Health insurers, Municipalities, client groups, users of health-related social services, provider organizations
|Medienpräsenz||sehr gering||sehr hoch|
An interesting policy idea; may be effective; highly unlikely that the reform will be revoked in future.
One of the political backgrounds of the LSS is to make consumers in health-related social services less dependent on public provision. If possible, they should organise these services themselves, for instance by means of informal care. Patients (clients) are only eligible to social support if there are no other options available. Another political background is that social care should be integrated with other public services, in particular housing, neighbourhood services, 'meals on wheels' and so on. The government believes that local government is better capable than health insurers to provide an integrated set of social support services. Opponents claim that the LSS is intended as a vehicle to implement expenditure cuts in health-related social support, but this is explicitly denied by the government.
There is a link with EU-legislation, because municipalities are obliged to meet the EU-regulations on public procurement (competitive bidding) when contracting with the provider organisations.
There is a need for cost-effective (integrated) care at the local (municipal) level.
|Implemented in this survey?|
The LSS which was initiated by the present government relates to the more general policy debate about the future of the AWBZ. The health-related social services now decentralised to municipalities were previously covered by the AWBZ, which is a social health insurance arrangement originally intended for exceptional medical expenses (mainly long-term care). However, since its inception in the mid-1960s various health services which had little or nothing to do with long-term care or exceptional medical expenses, were included in the health services package ('basket') of the AWBZ, mainly because of political opportunism. The LSS must not only create a more appropriate institutional setting for integrated care at the local level, but is also a policy tool to remove all those services from the basket of AWBZ which do not fit in its original goal: guaranteeing access to long-term care for the entire population. Thus, the LSS can be viewed an integral part of the ongoing health insurance reform (see also 2006-springtime report).
The LSS is best described as a new institutional framework for decentralising the provision of health-related social support to local government because municipalities considered the most appropriate government agent for delivering an integrated set of social support services to people who need that support to live independently as long as possible.
The approach of the idea is described as:
Local level - responsible for home care
Within institution - competitive bidding
The Ministry of Health was very much in favour because it had developed the idea and strongly believed that the LSS could help to resolve the problems in AWBZ and to achieve better integrated care at the local level.
Municipalities were divided over the issue. On the one hand, they were supportive because the LSS would enhance their opportunities in health care policymaking. On the other, they were afraid that the national government would 'abuse' the LSS to implement expenditure cuts in social support services.
Health insurers were neutral. There primary concern was that the shift of responsibility for health-related social support from health insurers to local government could lead to chaos.
Client organisations were not very supportive because of their fear for expenditure cuts. Furthermore, they considered local government as a 'unknown' partner in health care. A more fundamental objection raised was that the shift of social support services from social health insurance to local government could mean that clients would loose their right to social support services when qualified for it. Municipalities are not prohibited to make use of fixed budgets for social support services, whereas the concept of a fixed budget is not compatible, at least in principle, with the concept of insurance.
Providers were not very supportive. They preferred stable relations with health insurers. Provider organisations considered local governments as a source of uncertainty, because they would make use of the instrument of competitive bidding (public procurement) according to EU legislation. Com-petitive bidding could mean that they would lose a substantial part of their revenues to their competitors which could lead to bankruptcy.
|Ministry of Health||sehr unterstützend||stark dagegen|
|Municipalities||sehr unterstützend||stark dagegen|
|Provider organsations||sehr unterstützend||stark dagegen|
|Health insurers||sehr unterstützend||stark dagegen|
|Client organisations||sehr unterstützend||stark dagegen|
The LSS was rather controversial during the legislative process. A very important issue was how to protect the client right to social support services under the new regime. Whereas the AWBZ established a legal right to social support services when the client met the eligibility criteria, the LSS does not establish a similar right. Various political parties sought to reconfirm the right to social support services under the new regime, but it remains to be seen how it will work out in practice.
|Ministry of Health||sehr groß||kein|
|Provider organsations||sehr groß||kein|
|Health insurers||sehr groß||kein|
|Client organisations||sehr groß||kein|
The Law on Social Support is being implemented. A new interesting phenomenon is that local governments are now setting up procedures for competitive bidding in order to contract with provider organisations. The use of the competitive bidding instrument illustrates again the advance of market competition in health care delivery.
No monitoring and evaluative reports available.
No systematic evaluation available. Some provider organisations complain in public that they lost competitive bidding. Some reports in the media on substantive dismissals.
Outcomes are difficult to predict. Due to decentralisation one may expect local variations concerning the terms of the competitive bidding, co-payment rates, eligibility criteria, and so on.
|Qualität||kaum Einfluss||starker Einfluss|
|Gerechtigkeit||System weniger gerecht||System gerechter|
|Kosteneffizienz||sehr gering||sehr hoch|
System may become less equitable due to inter-municipal variation. For example: municipality A may use other eligibility criteria than municipality B.