Future scenarios for healthcare are becoming increasingly ominous. If growth continues like this, healthcare will take an increasingly large bite out of our total budget and will become unaffordable. Staff are not available or leave care early in frustration. Not everyone gets a GP anymore, the knowledge institute Nivel predicts that in certain regions GP care can no longer be provided within a year.
So we have to take a step back and the Bernhoven hospital put that into practice. Unnecessary care was scrapped, only appropriate care was provided. But yes, the chimney has to smoke, so shortages will arise in the current production-driven healthcare system.
Friend and foe have now agreed that something fundamental needs to change in this healthcare system. According to the Dutch Healthcare Authority (the NZa, which deals with the financing of healthcare), the production incentive must disappear completely and everywhere. And fast too. The Scientific Council for Government Policy (WRR) also recommends fundamental changes. But how?
Room elephant: the health insurer
Health insurers have to change, but the system cannot change them. A different basic package, concentration of emergency care, chronic care outside the hospital (has been happening for a long time) and viewing and radio license fees. But the elephant in the room, the directorial role of the health insurers, imposed on them by politics and not fulfilled, is strangely not up for discussion. And that’s strange.
Healthcare providers and health insurers do not trust each other at all. This was revealed in a recently held survey (by the VvAA healthcare association) among two thousand healthcare providers, in which less than 13 percent have confidence in the care director. This must have a negative effect on the quality of care.
Primary care providers in particular suffer more than health insurers benefit. Rates cannot be adjusted within three months, healthcare innovation such as ‘more time for the patient’ is stopped due to financial problems in the hospital, appointments are not carried out (€16 billion less was paid out than agreed), anti-fraud measures have been taken in view of the fraud rates disproportionate and distrust leads to an abundance of rules, requirements and administrative provisions.
Delete director role
What does the primary care insurer actually add? Wouldn’t it be better to cut that director’s role? Starting with general practitioner care, community care and paramedical care (10 percent of the total healthcare costs). The care closest to the citizen, the care that benefits from long-term relationships, trust, small scale, cooperation and local or regional networks, and actually without market forces.
The Competition Act (Mw) prevents the health insurer from functioning as a director but as a utility. Small-scale care providers are seen as entrepreneurs who sell the product ‘care’ to citizens in their (practice) shop. They have to compete with fellow health care providers, with whom they also work. But the NZa determines the rates for 90 percent, the rest is governed by the competition law. And you are not allowed to negotiate with the health insurer together. So there is no negotiation.
European rules help
Scrapping the competition law for primary care will run into European regulations. However, European law does offer the possibility to designate certain services as services of general economic interest (SGEI). Member States have their own discretion in this regard.
This can also be applied in (primary) care. Within the Dutch health care sector, basic health insurance is also a service of general economic interest, ie a SGEI. After all, health insurers are compensated via the risk equalization fund for the fact that they have to admit everyone, including the sick and the elderly, to their basic insurance. There must then be a ‘market failure’. If there are no more GPs in shrinking regions, the market will fail. It is actually very logical to have basic healthcare as a SGEI connected to the basic insurance as a SGEI.
By not removing these basic care providers directly from the health care system, but from the competition law, they will continue to fall under the Wmgo (Healthcare Market Regulation Act). However, the health insurer is no longer a director, but becomes a utility, a conduit for policy rules and rates established by the NZa. And of content determined by one’s own profession.
Political choice
So the countervailing power remains. It has been proposed three times before. It could be soon. Two ministers, the Minister of Economic Affairs and the Minister of VWS, must have new policy rules established by the regulators ACM and the NZa. It is a political choice, no law needs to be changed.
Then make sure that health insurers are once again obliged to offer this group a neatly simple payment agreement, two A-fours (I provide care according to professional standards and you pay without reservation according to the NZa rates). That saves a lot of administrative regulations.
Invest saved administration costs and the underspent and thus withheld 16 billion in this group by stimulating practice reduction (more time for the patient) and small-scale. Autonomy, personal attention and trust in the care provider thrive best in a small-scale setting.
Smaller Practices
With a new tariff structure, the NZa should organize and simplify the tariffs in such a way that the reduction in practice and small-scale use are encouraged. Jumping through the hoop of the health insurer can then be cancelled.
Fundamental change without immediately turning the whole system upside down. Start small, at the base. The coordinating role is then returned to the professionals in the field, the countervailing role to the supervisors and no longer to the health insurer. But the minister must then make a choice that has been postponed far too long.
Herman Suichies is a former general practitioner and former board member at VPhuisartsen.