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111025 kias apria presentation def

  1. 1. Healthcare in The Netherlands: Combining competition and solidarityPublic/private elements for building 21st century healthcare KIAS – APRIA – International Symposium on Health Insurance Seoul, 03 November 2011 Piet de Bekker
  2. 2. Introduction• Founder & co-owner of zorgVuldig Advies, consultancy firm, specialised in health care strategies• Board member Dutch-Flemish Health Economists Association• Board member Foundation the Healthcare Embassy• Policy advisor Dutch Ministry of Health – Coordinating participation of OECD Health Project (2001- 2004) – Exchange program United States, Dept HHS KIAS APRIA Symposium | 03-11-2011 2
  3. 3. 1. Private Health Insurance: The Michael Moore effect KIAS APRIA Symposium | 03-11-2011 3
  4. 4. Distribution of Health Plan Enrollment for Covered Workers, by Plan Type, 1988-2011 1% 1% 1% 1%* Distribution is statistically different from the previous year shown (p<.05). No statistical tests were conducted for yearsprior to 1999. No statistical tests are conducted between 2005 and 2006 due to the addition of HDHP/SO as a new plantype in 2006.Note: Information was not obtained for POS plans in 1988. A portion of the change in plan type enrollment for 2005 islikely attributable to incorporating more recent Census Bureau estimates of the number of state and local governmentworkers and removing federal workers from the weights. See the Survey Design and Methods section from the 2005Kaiser/HRET Survey of Employer-Sponsored Health Benefits for additional information. KIAS APRIA Symposium | 03-11-2011Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2011; KPMG Survey of Employer-Sponsored 4Health Benefits, 1993, 1996; The Health Insurance Association of America (HIAA), 1988.
  5. 5. There is an alternative … KIAS APRIA Symposium | 03-11-2011 5
  6. 6. Agenda1. Private Health Insurance – the Michael Moore effect2. Health Systems in Europe: public and/or private3. Netherlands: the basics4. Health System in The Netherlands5. Recent Health Insurance reforms6. Towards sustainable healthcare through effective competition KIAS APRIA Symposium | 03-11-2011 6
  7. 7. 2. Health Systems in EuropeThree basic models of health financing KIAS APRIA Symposium | 03-11-2011 7
  8. 8. Beveridge: state-run and tax-funded nationalhealth service providing free-of-chargehealthcare services for the entire populationthrough mainly publicly-owned facilities andsalaried staff.Beveridge:-Tax-Government-Public service KIAS APRIA Symposium | 03-11-2011 8
  9. 9. Semashko: centrally-organised and state-financed healthservice in the former socialist countries with publiclyowned healthcare facilities and different levels of stateadministration responsible for planning, allocation ofresources and managing capital expendituresSemashko:-Government-Complete control-Tight planning KIAS APRIA Symposium | 03-11-2011 9
  10. 10. Bismarck: systems of social insurance, fundedout of income-related contributions (pay-rolltaxes) and administered by (semi)-publicsickness funds, ensuring financial protectionagainst the risk of healthcare costs.Bismarck:-(Social) Insurance-Employers &employees-Public-private mix KIAS APRIA Symposium | 03-11-2011 10
  11. 11. Worldwide: 1. Right to receive health care: three waves Universal Coverage and Equal Access says: David M. Cutler in The Dynamics 2. Controls, of International Medical-Care Reform Rationing, Expenditure Caps 3. Incentives and Competition to guide demandSource: Journal of Economic Literature Vol. XL (Sept 2002),pp. 881-906 KIAS APRIA Symposium | 03-11-2011 11
  12. 12. 3. Netherlands: the basics• tulips• windmills• wooden shoes• cheese• bikes• canals, water management• Amsterdam (capital)• coffee shops KIAS APRIA Symposium | 03-11-2011 12
  13. 13. Also relevant to know• small country• 16.5 million inhabitants, high population density• GDP/capita: €28.900 (2010)• open economy (traders)  economic incentives• European history  social principles• mix of influences (religion, culture)  pragmatic• government coalitions  agreement KIAS APRIA Symposium | 03-11-2011 13
  14. 14. 4. Health System in The Netherlands KIAS APRIA Symposium | 03-11-2011 14
  15. 15. Some institutional characteristics1. Private insurers (choice for-profit/non-profit)2. Principles of managed competition. Tradition of negotiating, mediating, and co-governing with the major interest groups (polder model)3. Maximizing risk-solidarity, (e.g. low out-of-pocket expenses; community-rating; risk-adjustment)4. Private providers (hospital, physician, pharmacy). Gatekeeper is the family physician5. Large general acute-care hospitals; but care is normally ‘around-the-corner’ (GP)6. Small acute health care sector; large long-term care sector KIAS APRIA Symposium | 03-11-2011 15
  16. 16. Netherlands health expenditure before … KIAS APRIA Symposium | 03-11-2011 16
  17. 17. … and after our reforms KIAS APRIA Symposium | 03-11-2011 17
  18. 18. 5. Recent Health Insurance reformsThe Dutch Approach:the essence of competition… is to experience the effects of your performance. Therefore it disciplines and motivates!Many evolutionary biologists view inter-species and intra-species competition as the driving force of adaptationand ultimately, evolution.But competition is a means and not a goal… KIAS APRIA Symposium | 03-11-2011 18
  19. 19. New system: social elements  access, solidarity, quality• Individual mandate to take out insurance• Standard benefit package of essential healthcare• Risk adjustment scheme to prevent risk selection• Tax money used to pay for children <18• Community rating (same premium for same policy)• Tax compensation for low incomes• Supervision on quality and anti-trust KIAS APRIA Symposium | 03-11-2011 19
  20. 20. All OECD countries have achieved universal or near-universal health care coverage, except Turkey, Mexico and the United States 2007Source: OECD Health Data 2009, OECD (http://www.oecd.org/health/healthdata).
  21. 21. Low-income populations more often report unmet care needs due to cost, but there are large variations across countries Unmet care need* due to costs, by income group, 2007* Did not get medical care, missed medical test, treatment or follow-up, did not fill prescription or missed doses.Source: Commonwealth Fund (2008).
  22. 22. New system: market elements  financial sustainability, quality• Private insurers (profit/non-profit)• Individual contracts, annual open enrolment• Nominal premium  price incentive• Policies may differ. Voluntary deductible? Benefits in kind? Group insurance?• Some cost sharing• Competition between insurers drive negotiations with providers (selective contracting)• Transparency KIAS APRIA Symposium | 03-11-2011 22
  23. 23. Premiums actually differ between insurers KIAS APRIA Symposium | 03-11-2011 23
  24. 24. Choice is the driving force KIAS APRIA Symposium | 03-11-2011 24
  25. 25. Results – midterm review• Premiums initially lower than projected, currently accelerating (8-10%)• Mobility high at first, but low ever since (2006: 18%, 2007-2011: 3-6%) – yet, people are aware• Group insurance contracts are driving force• Low number of uninsured, increasing number of defaulters  new (public) interventions• Mergers• Contracting providers on price and quality• Window of opportunity for all kinds of innovation• Remarkable upward shift in life expectancy (+2 yrs) KIAS APRIA Symposium | 03-11-2011 25
  26. 26. 6. Towards sustainable healthcare through effective competitionThe system is sown, but the real harvest has yet to come… KIAS APRIA Symposium | 03-11-2011 26
  27. 27. What’s next• Performance based payment (DBC)• Further liberalizing (price, volume)• More diversity• Innovation: new providers / creative destruction (Schumpeter)• Information on quality• Focus on public health and prevention (behavior and disease management programs)• Reform long term care (parts have been transferred to municipalities or health insurers) KIAS APRIA Symposium | 03-11-2011 27
  28. 28. Main lessons• New health insurance• Combining solidarity and market incentives• Guarantee quality and access: public requirements• Stimulate quality improvement and efficiency/ affordability: tools for buying best care• Choice is the driving force to improve performance! KIAS APRIA Symposium | 03-11-2011 28
  29. 29. Thank you for your attention!Questions / comments: pietdebekker@zorgvuldigadvies.nl www.zorgvuldigadvies.nl KIAS APRIA Symposium | 03-11-2011 29

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