Primary Care in The Netherlands: General Practitioners in the Lead

Jako Burgers, MD, PhDDutch College of General Practitioners

Common Wealth Fund Webinar

February 5, 2013

2Characteristics of the Dutch health care system

• Complete coverage for all residents (< 1% uninsured)

• All patients are registered in one general practice

• General practitioner is gatekeeper to hospital and

specialist care

• Balance between external, governmental systems and

internal, professionally led systems for quality

improvement

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• 10,000 general practitioners (GPs), 7,800 own practice

• 100% have practice assistant, 80% practice nurse

• GP is family physician covering whole population • GPs offer out-of-hours service covering whole country• 60% of income is capitation fee, 30% fee-for-service,

10% special services (1-2% P4P)• No co-payment for GP visit• Satisfaction with GP is high (8 on scale from 0 to 10)

Primary Care in Netherlands: Basic Characteristics

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Health Information Technology

• Eight different software programs for general practice

• All support electronic drug prescription, incl. prompts

• Most support ordering of laboratory testing, imaging,

and referral to hospital care, incl. info on waiting time

• Generating panel information and feedback on

performance is slowly improving

• E-mail consultation and refill request is increasing

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Access and perceived barriers

• Increasing problems with paying bills or out-of-

pocket costs: from 5% in 2007 to 42% in 2012

• Significant reduction of coverage in basic health care

package and increasing premiums in 2012

• Waiting times have reduced due to increasing

competition between hospitals and public reporting

• Access to GP and after-hours care is well perceived

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Care Coordination• Practice nurses support chronic care (diabetes, COPD,

cardiovascular risk management), and increasingly elderly care

• Involving specialized practice nurse in mental health care is ongoing

• Communication between medical specialist and GP:– brief message on same day on hospital admission and discharge– full letter after 2 to 4 weeks (on paper or electronically)– phone consultation on demand– use of local protocols strongly varies per region

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Financial incentives

• Additional care contracts on diabetes, COPD, and cardiovascular risk management (some insurers)

• Flu vaccination ($ 12 per patient), cervix screening ($ 14 per patient)

• Practice nurse (0.4 fte per 2,350 patients)• $ 20 for home visits versus $ 10 for doctor visits and

$ 5 for phone calls

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Quality Assurance

• Continuing Medical Education is mandatory for re-license (every 5 years)

• Participation in peer review groups is mandatory• 40% of GPs applied for practice accreditation, including:

Assessment of organizational/structural capabilities Clinical performance feedback Patient satisfaction survey

• National research institute and some insurers provide feedback on test ordering and hospital admission

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Key factors for success:

•National government supports primary healthcare

•Strong, well-accepted national professional organization

•Payment system supports regular doctor and integrated patient care

•Longstanding evidence-based guideline program

•Collaboration and local peer support are essential

Can other countries learn from Dutch general practice?

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