More and more health insurers are canceling the reimbursement policy. This is a policy for which policyholders pay a higher premium and therefore receive full reimbursement for care from providers without a contract with the insurer. With the standard policy, this care is only reimbursed at 75 percent of the average rate of contracted providers.
Three of the four largest insurers – VGZ, CZ and Zilveren Kruis – are converting the reimbursement policy into a combination policy, by no longer fully reimbursing non-contracted mental health care and community nursing. Other non-contracted care is still fully reimbursed for insured persons with a combination policy. VGZ announced this decision last year and now reimburses 90 percent of non-contracted mental health care and community nursing. Last year there was a transitional arrangement in which insured persons could complete their treatments with non-contracted providers. CZ and Zilveren Kruis will soon reimburse 85 percent, but will still apply the same transitional arrangement in 2024.
Menzis, ASR and Aevitae will keep the policy in its current form. “There is still a need for this for some of our policyholders,” says Dirk Jan Sloots, financial director of Menzis.
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Worries about waiting lists
The disappearance of the reimbursement policy restricts the free choice of doctor: insured persons can no longer opt for a policy where all care is reimbursed. Mental health care advocate MIND is concerned about this, because there are often long waiting lists, especially for contracted mental health care, and alternatives are now becoming more expensive. Director Dienke Bos: “The reimbursement policy was an escape from long waiting lists at providers with a contract.”
Bos expects that these waiting lists will now grow, because people who previously had a reimbursement policy will also end up on it. “And waiting lists result in avoidance of care. A great danger with mental problems.” Providers without contracts are usually smaller, she says, and cannot handle the administrative burden of contract agreements. In addition, insurers often impose conditions that healthcare providers cannot meet, such as a minimum turnover of 50,000 euros.
Article 13 of the Health Insurance Act sets out the ‘obstacle criterion’: there may be no obstacle to care. This guarantees a certain degree of free choice of doctor: health insurers must reimburse all registered care, even from providers without a contract. But this does not have to be at the full rate. Typically, care from non-contracted providers is reimbursed at 75 percent, except in the case of a reimbursement policy, where all care is fully reimbursed.
According to Xander Koolman, health economist at the Vrije Universiteit in Amsterdam, it is inevitable that mental health care and community care can no longer be covered by a reimbursement policy. The idea of Article 13 and the ‘obstacle criterion’ was that insured persons would make a personal contribution of 25 percent for non-contracted care, he says, which should encourage care from contracted providers. This worked in most sectors: providers there preferred a contract. This did not apply in mental health care and home care. Koolman: “That’s where it happened [artikel] seen as an opportunity to get rid of the health insurer – and therefore all kinds of conditions for, for example, effectiveness and efficiency.”
There were two ways to retain patients: waive the 25 percent personal contribution or encourage patients to take out a reimbursement policy. “The latter in particular happened a lot. This resulted in a large flow of patients to that policy from people who need a lot of care – because patients who use little care do not opt for a more expensive policy. And so the refund policy became completely loss-making.”
Koolman also sees that the route to circumvent long waiting lists via a reimbursement policy – “in healthcare sectors to which the government and insurers do not want to give priority” – now appears to be cut off for many insured people. “But he should never have been there in the first place,” says Koolman. “People who need insured help should get it regardless of their policy.”
Last year, 84,000 people were on a waiting list for mental health treatment. In 2019 (the most recent figures), more than 82,000 people were treated in mental health care by non-contracted care providers, according to figures from healthcare knowledge center Vektis. If that non-contracted care disappears, “you double the waiting list in one fell swoop,” says Ger Jager, chairman of the Free Doctors’ Choice Enforcement Foundation. He expects that most people will not be able to pay their own contribution and will therefore be forced to purchase contracted care.
Won’t many of those providers simply enter into a contract with an insurer? No, Hunter thinks. “It is very difficult to get a contract. Many mental health providers are willing to do so, but they receive rejection after rejection in a standard email.” For example, health insurers send rejections because enough care has already been purchased, an institution does not meet the turnover requirements or offers too little online care. According to Jager, the non-contracted providers fulfill an important function. “They fill the gap that is created by too long waiting lists, if insurers do not contract enough providers.”
Georgette Fijneman of Zilveren Kruis hopes to contract more providers with the measure and to encourage them to do so, especially in the more demanding mental health care. “There we see the longest waiting lists, and much fewer providers than in light mental health care. We want to encourage providers to also provide complex mental health care and are therefore increasing the reimbursements for this. In this way we hope to reduce those waiting lists.”
The fact that there are now only three health insurers left with a reimbursement policy is worrying, according to Koolman. He predicts that policyholders who had a reimbursement policy elsewhere will switch to one of the three remaining insurers. “These are heavy healthcare users and therefore expensive insured people. The remaining reimbursement policies will therefore become heavily loss-making and will probably also stop. A spiral of death.”
Menzis also sees that risk, says Sloots. “If that indeed happens, we will have to reconsider our decision. It could be that the market will ultimately force us to discontinue the policy as well.”