The Health Insurance Act is clear about who has what role in the Dutch health care system. The Ministry of VWS, health insurers, care providers, the patient and the regulator, each have their own duties and responsibilities. But in practice there is role reversal and role renunciation.
About the author
Christian Romans is an orthopedic surgeon and medical director of OCON Orthopedic Clinic.
Healthcare providers, such as hospitals, have taken on tasks from others. They take on much more responsibility than the law prescribes. Whether it concerns the insurance risk, the aging population, population growth, inflation or absenteeism, the healthcare institution itself is responsible for the consequences. Nurses, doctors and other healthcare workers feel that every day. In the form of an ever-increasing workload and growing bureaucratic red tape.
Budget keeper
Role reversal One is that between the government and health insurers. The government determines the content of the basic package and how much money is spent on health care each year: the budgetary care framework (BZK). Health insurers must offer everyone insurance that provides easy access to high-quality care at an affordable premium. Because the cabinet could not keep expenditure under control, it was looking for a budget guard. The health insurers took on that role.
Ten years of budgeting and a pandemic further, the accessibility of healthcare is rapidly decreasing thanks to long waiting times, high workloads, wage arrears and a financially distressed healthcare sector. The political promise of easily accessible basic care is gradually becoming a false promise for many people. In the meantime, health insurers continue to perform their role as budget guardians.
Shifted risk
Role reversal two is that between health insurer and health care provider. The health insurers negotiate the budget with care providers every year. These are tough contract negotiations. If a hospital then has to provide more care than the budget allows, it will not be paid for it. For example, the risk associated with insurance has been shifted from insurers to hospitals and other healthcare providers. Nowhere in the Healthcare Insurance Act has it been agreed that healthcare providers must also act as an insurance company.
Why healthcare administrators voluntarily and collectively take on this role reversal is downright puzzling, because it always leads to unpredictable financial shortfalls at healthcare institutions.
Role renunciation
We see role relinquishment among the supervisors. De Nederlandsche Bank, for example, which supervises the financial sector, sets strict requirements for health insurers. They are required to hold large reserves to cover their insurance risk. And while insurers maintain and increase their reserves, they pass on their risk to the healthcare institutions. Supervisors know this and tolerate this. So role renunciation.
And patients suffer. By the end of the year, they must travel to a place where there is still some care budget left (waiting list mediation). Or wait until the new year when a new budget becomes available.
With hospitals entering a price-wage spiral due to inflation and high wage demands, a growth in healthcare expenditure is inevitable. Hospital administrators and the Dutch Association of Hospitals are hating it, but health insurers and VWS are not giving in for the time being. That is ostrich politics. Without extra budgetary space, almost all hospitals will run into major financial problems next year. The tight frameworks of the recently concluded Integrated Care Agreement have already been overtaken by the reality of rapid price increases.
JROJP
In order to avert doomsday scenarios, it is first of all necessary for hospital administrators to limit themselves to their own role. If they refuse to take on the insurance risk any longer in 2023, no longer accept budget caps and no longer conclude loss-making contracts, then that role reversal will be lifted. The insurance risk then lies where it belongs: with the health insurer. JROJP: Right Risk in the Right Place. The insurers must then set a realistic premium for the basic health insurance.
And then it becomes painfully visible that the premiums are far too low to be able to fulfill everything that the health care policy currently promises for everyone. Because the basic healthcare policy cannot become much more expensive, there is no other option than to finally open the political and social debate about choices in healthcare. So about the question of what we are willing and able to spend on care together and what you as a citizen can expect in return.
Do you want to respond? Send an opinion contribution (max 700 words) to [email protected] or a letter (maximum 200 words) to [email protected]