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Transcript of The 2006 Health Insurance Reform in the Netherlands – introducing universal coverage Prof. Peter...
The 2006 Health Insurance Reform in the Netherlands – introducing
universal coverage
Prof. Peter P. Groenewegen, PhD
Dublin, December 6, 2010
Health care insurance law
• Introduced on 1 January 2006• Abolition of distinction between
private and public insurance• Insurance under private law with
public limiting conditions• Obligation for every citizen to take
health insurance• Part of larger reform, aiming at
higher quality and lower costs
Dutch health insurance until 2006
Public insurance (65%):• obligatory for all
employees and dependents below income ceiling;
• no risk selection;• no premium
differentiation;• premiums largely income
related with small nominal premium
• administered through sickness funds
Private insurance (35%):• not obligatory;• for people above income
ceiling;• admitted after risk
selection;• premium differentiation• premiums nominal and
risk related• administered through
damage insurance companies and sickness funds
Introduction period
• Large number of switchers (18%); now stabilized at former levels of appr. 4%
• No big administrative problems for insurance organisations
• More administrative problems for GPs (concurrent change of payment system)
Why did it run so smoothly?
• Long history: starting in 1987• From early 1990’s: many small
steps in regulation• Anticipation and adaptation by key
actors in the systemThese steps made insurance reform
both possible and inevitable
The fate of the Dekker committee report 1987
• 1988 government accepts the Dekker plans.• 1989 shift of government coalition from
Christian-democrats and conservative liberals to Christian-democrats, labour party and liberal democrats.
• 1990 adapted Dekker plan, known as plan Simons.
• 1993 end of plan Simons.• 1994 shift of government coalition to labour,
liberal democrats, and conservative liberals; no-regret policy of small steps.
Between 1990 and 2006 the following (small) steps were
taken• regional monopolies of sickness funds
abolished, • publicly insured free to chose a sickness
funds, switch once a year,• financial responsibility of sickness funds
gradually increased,• obligation to contract all providers
removed for ambulatory care providers,• development of a risk adjustment system,• from fixed tariffs to maximum tariffs
Anticipation and adaptation: the case of one health
insurer • Mergers with other sickness funds
(competition, financial risks)• Integration of administrative
procedures• Harmonization of insurance policies• Customer orientation• Contracting collectives in private
insurance• Developing the purchasing function
• Basic package (identical for everybody)
• Choice between in-kind and restitution policy
• Additional insurance (no obligation to accept everybody)
• Obligatory deductable €165• Free choice of extra deductible
(min. €100, max. €500)
Health insurance and insured
insurance policy
Health insurance and insuredfinancing
• Premium: nominal (circa €1100 per year) plus income dependent (via taxation, obligatory restitution by employer)
• Collective arrangements against reduced nominal premium
• Compensation for low income persons• Nearly 40% of adults benefit from
compensation; on average €480
• Compensation for chronically ill and disabled
• obligatory deductable is compensated
Health insurance and insuredaccess
• Obligation to accept everybody, risk selection and premium differentiation forbidden
• Free choice between insurance organizations
• Risk equalization between insurers• Possibilities for risk selection
• Additional insurance• Collective insurance• Preferred provider contracts
Uninsured• May 2006: 173.000• May 2007: 151.000• May 2008: 153.000• May 2009: 152.000• Approx. 1% of total
population• Over-representation
of migrants and younger people
Bad payers• Dec. 2006: 190.000• Dec. 2007: 240.000• Dec. 2008: 279.000• Dec. 2009: 318.500• Approx. 2% of adult
population• Over-
representation of migrants, social security dependents, one-parent families
Health insurance and insured
access
6%
3%2%
29%
21%
13%
9%
5%4%
6%
4%2%
4%
1%
8%
till 39 years 40 - 64 years 65 years and over
switched (2005)
switched (2006)
switched (2007)
switched (2008)
switched (2009)
Source: Dutch Health Care Consumer Panel
Health insurance and insuredswitching health insurer
Health insurance and insured What were reasons for switching?
9%
15%
18%
41%
56%
14%
14%
18%
36%
37%
11%
13%
28%
25%
11%
7%
7%
24%
39%
22%
0% 10% 20% 30% 40% 50% 60%
service insurancecompany
coverage
complementaryinsurance
premium
collectiveinsurance
2009200820072006
Source: Dutch Health Care Consumer Panel
Health insurance and insured Collectives
• Employers• Patient organizations• Unions• All other kinds of groups (lotteries,
stores, etc)• 65% has collective insurance • Discount on average 7%
2%
72%
10%
4%
12%
patient organizationemployerunionmunicipalityother
Source: Dutch Health Care Consumer Panel
Health insurance and insured Collectives
• For employers : premium, discount for basic and additional insurance were most important
• For patient organizations: service, coverage and discount for additional insurance were most important
Source: questionnaire amongst 42 organizations. Van Ruth, De Jong and Groenewegen, 2007
Health insurance and insured Collectives
• Employers base their choice on price• Patient organizations value content• Quality improvement is possible
through patient organizations efforts• However, they are a minority, and
mobilize less insured • It took more effort and they received
lower discounts
Health insurance and insured Collectives
Health insurers and providerscontracts and financing
• Obligation to contract enough care to provide for insured with in-kind policy
• Obligation to mediate between providers and insured with restitution policy
• Preferred provider contracts• For 34% of hospital care prices are
negotiable
• Health insurers need information about performance of providers
• Performance information is still scarce
• Examples: Consumer Quality-index and indicators required by the Health Care Inspectorate
• Contracts can then be related to performance indicators
Health insurers and providers
contracts and financing
• Erosion of mutual trust, affecting the willingness to cooperate
• Crowding out of professional values• Much supervision – high costs, low
trust
Health insurers and providers
unintended consequences of competition
Competition in my work is …..
Percentage with (very) much trust in good intentions
Very small 68%
Small 68%
Not big, not small 62%
Big 48%
Very big 37%
Unintended consequences of competition: less trust among
providers of health care
Provider and patientaccess
• Gate keeping system: no free access to specialist care
• Freedom of choice of provider can be restricted for insured with in-kind policy
• Insurance organization may have negotiated specific care programmes
Can insurers guide patients?• There are positive incentives: the
obligatory deductable is not paid for preferred providers
• Only few examples of insurance policies with selective contracting
Provider and patientaccess
Effects of reforms: Quality of care
• Quality is hardly part of negotiations between insurers and providers, price is most important
• Insured choose their insurer based on premium, not on quality
Effects of reforms: Cost containment
Cost containment is difficult in demand driven system
• Micro versus macro efficiency: Prices may decrease, volume is increasing
Options in case of increasing costs:- restriction of basic package- shifts towards additional insurance
- increased cost sharing- decreased compensation for lower income people