Towards patient oriented funding of chronic care

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

Abstract

This policy combines ideas about patient oriented care (as opposed to supply dominated care) and disease management programmes for chronic diseases by developing a new funding system. Patient oriented funding integrates care from different providers in primary or secondary care. It can be provided by groups of care providers from primary or secondary care and can be purchased by health insurance organisations. Patient oriented funding will be introduced in January 2010 for four disease groups.

Purpose of health policy or idea

Patient oriented funding of chronic care (in Dutch: functionele bekostiging) combines ideas about patient oriented care instead of supply dominated care on the one hand and disease management programmes for chronic diseases by developing a new funding system. Patient oriented funding integrates care from different providers in primary or secondary care. It can be provided by groups of care providers from primary and/or secondary care and can be purchased by health insurance organisations. The care programme has to follow the standards of care developed by the health care providers involved in the care for the specific patient/disease group, the patient organisations and insurance organisations. The Ministry of Health aims to introduce this new type of funding in January 2010 for four disease groups: diabetes, COPD, heart failure, and management of cardiovascular risk factors.

Under the new funding, the care for these disease groups will be organised around the needs of patients by integrating care provision of different providers. Care will be organised by groups of providers that both provide general and more specialised care, and that negotiate a lumpsum for each patient. Provider groups can either provide care themselves or sub-contract to other providers. E.g. a group of general practices might contain GPs with a specialization who can provide more specialised services for all patients in their group, or alternatively, the group might contract medical specialists to provide these services.

Provider groups can be integrated health centres in primary care, groups of cooperating general practices and/or hospitals. Insurance organisations can then purchase care from these groups.

It is expected that in the policy to be introduced groups will have to provide general care as well as more specialized care, tuned to the specific disease groups. Therefore, GPs will be the core providers in the groups. It is also expected that one group will provide care for all four disease groups to prevent fragmentation of care.

Main points

Main objectives

Main aim is to improve care for the chronically ill. This will be realised by organising care around patients' needs instead of around care providers. Patient oriented funding will integrate care of different providers in primary and secondary care.

Type of incentives

Financial: special tariffs for the integrated care for four patient groups, based on care standards

Non-financial: care has to be provided in accordance with standards of care specifically developed to support integrated care; performance indicators have to be formulated.

Insurance organisations purchase this care from provider groups.

Groups affected

Patients with diabetes mellitus, patients with chronic obstructive pulmonary disease, patients with heart failure, patients at risk for developing cardiovascular disease

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

These are the first steps of making funding of health care independent of the specific health care organisation or profession that provides care. This might have a big influence on the way the system of regulated competition in the Netherlands will develop and on the purchasing behaviour of insurance organisations.

As yet the public visibility is rather low; the four patient/disease groups constitute 13% of the practice population of modal GP and one third of the patient contacts (Van Dijk et al, 2009).

Political and economic background

The policy is based on previous policy notes about the care for chronically ill and about primary care. It fits in the general transformation of the Dutch health care system from a supply dominated to a patient oriented care system. It also aims at stimulating and facilitating insurance organisations to purchase care based on quality and price.

Change based on an overall national health policy statement

Letter from the Minister of Health to the 2nd Chamber of Parliament 22 December 2008 titled Patient centrality through patient oriented funding.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

Basically this is an old idea of funding care irrespective of the specific provider, instead of funding care as provided by e.g. general practitioners or hospitals or specific specialties. This idea was already formulated during the early debates about health reform in the Netherlands in the late 1980's. The idea is that the chronically ill do not need care provided by a GP, a hospital and a medical specialist. Instead they need types of care that can be provided by different kinds of professionals and organisations, as long as it is tuned to their needs, multidisciplinary and integrated. The policy resembles disease management programmes, as introduced elsewhere (Gress et al, 2009).

Managed competition is supposed to be stimulated if care is no longer defined in terms of the specific providers of care but in terms of the characteristics of the type of care needed by patients. In that case insurance organisation can purchase this type of care from every group of prividers that is able to deliver it against good quality standards and a competing price.

The main actors are the Ministry of Health, the patient organisations, the insurance organisations and the organisations of care providers.

At local level, groups of general practices now organise themselves on a regional scale in so-called Care Groups, to contract with insurance organisations to provide care for specific patient groups. (De Wildt JE, Leusink G, 2008).

Initiators of idea/main actors

• Government: The MoH has described its policy in a letter to Parliament in Decmber 2008 and has set out to introduce the new funding scheme in January 2010.

• Providers: GP organizations range from neutral (College of GPs) to positive (Association of GPs) provided that patient oriented funding of chronic care is part of an integrated care supply (and not restricted to care specifically related to the chronic disease).

• Payers: Insurance organisations are generally in favour of the policy, because it increases their possibilities to purchase care based on quality and price and performance indicators.

• Patients, Consumers: NPCF, the national federation of patient and consumer organisations, supports patient oriented funding but emphasized the need for integrated care. Disease oriented care should always be coupled to generalist care.

Approach of idea

The approach of the idea is described as:
new: Altough the idea is not new and disease management programmes exist in several countries, for the Dutch situation this policy is new.

Innovation or pilot project

Local level - For some types of care (such as diabetes care) insurance organisations purchase care from groups of GPs, that provide integrated care for these patients.
Pilot project - ZonMw (Netherlands Organisation for Health Research and Development) subsidizes 10 projects with diabetes care groups, to be evaluated by RIVM.
Else - Disease management programmes have been studied in the Netherlands; however, new is the funding part (Steuten et al, 2006).

Actors and positions

Government
Ministry of Health	very supportive		strongly opposed
Providers
Dutch College of GPs	very supportive		strongly opposed
Dutch Association of GPs	very supportive		strongly opposed
Payers
Big insurance organisations	very supportive		strongly opposed
Patients, Consumers
NPCF	very supportive		strongly opposed

Influences in policy making and legislation

The Ministry of Health will further develop the policy and will report about it by Summer 2009. The MoH will ask the Health Care Authority (NZa) to investigate how patient oriented funding of chronic care will reach its intended aims and how it changes the health care market and the behaviour of the actors in the health care market.

Legislative outcome

success

Actors and influence

Government
Ministry of Health	very strong		none
Providers
Dutch College of GPs	very strong		none
Dutch Association of GPs	very strong		none
Payers
Big insurance organisations	very strong		none
Patients, Consumers
NPCF	very strong		none

Positions and Influences at a glance

Review mechanisms

n/a

Expected outcome

One of the difficulties with this policy will be to define care for specific chronic diseases and to delineate this from care for other chronic diseases and general care. Research has shown that co-morbidity is very common in the age groups above 55 years; increasing from appoximately half of the people aged 55-64 to more than 80% in people aged over 75 (Schram et al, 2008). Moreover a majority of the contacts that people in one of the four chronic disease groups have with their general practice is not for the index disease but for something else (Van Dijk et al 2009).

This underscores the importance of integrated care and the difficulty in designing a funding system that is highly specific. Part of the policy is that patient oriented funding of chronic care is going to be taken out of the current funding. Consequently, if care for the four disease groups is separately funded, it has to be taken out of regular funding of general practitioner care.

Patient oriented funding of chronic care along specific disease groups runs the risk of fragmented care. Another unintended consequence might be shifts between normal general practitioner care and the specific funding for chronic care. Moreover, it might be unclear whose responsibility normal general care is.

Patients from the same general practice might have different insurance policies. Although usually the smaller insurance organisations follow the arrangements made between the dominant insurer and the general practices, situations might arise when GPs have to offer different arrangements according to where a patient is insured.

Finally, some people have voiced concern about the relationships between care providers when care groups start to contract specific primary and secondary care services on the basis of price.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

If care is provided according to care standards and performance is monitored, quality of care for the chronically ill may improve (this is the stated aim of the policy); although there might be unintended consequences. The system might be less equitable if patients are not well-informed about the care groups that are contracted by insurance organisations. The system of managed competition is driven by the choices that the insured can make. However, it is not sure whether the chronically ill will want to change to insurance organisations that have contracted care groups to provide chronic care.

References

Sources of Information

Ministerie van VWS. Dynamische eerstelijnszorg. TK 2007-2008, 29247 nr. 156

Ministerie van VWS. Programmatische aanpak van chronische ziekten. TK 2007-2008, 31200 XVI nr.155

Ministerie van VWS. Brief aan de Tweede Kamer betreffende: De patient centraal door functionele bekostiging. 22 December 2008

De Wildt JE, Leusink G. Nulmeting Zorggroepen: een beschrijvend onderzoek van de karakteristieken. Utrecht: LVG, 2008.

Schram MT, De Waal MwM, De Craen AJM, Deeg DJH, Schellevis FG. Multimorbiditeit: de neiuwe epidemie. TSG Tijdschrift voor Gezondheidswetenschappen 2008; 85:23-25

Van Dijk C, Rijken M, De Bakker D, Verheij RA, Groenewegen PP, Schellevis F. Kanttekeningen bij functionele bekostiging.

Steuten L, Vrijhoef B, Van Merode F, Weeseling G-J, Spreeuwenberg C. Evaluation of a regional disease management programme for patients with asthma or chronic obstructive pulmonary disease. International Journal for Quality in Health Care 2006; 18: 429-436

Gress S, Baan CA et al. Co-ordination and management of chronic conditions in Europe: the role of primary care. Quality in Primary Care 2009; 17:75-86

Author/s and/or contributors to this survey

Groenewegen, Peter P.

NIVEL - Netherlands Institute for Health Services Research

Suggested citation for this online article

Groenewegen, Peter P.. "Towards patient oriented funding of chronic care". Health Policy Monitor, April 2009. Available at http://www.hpm.org/survey/nl/a13/2