Before 2006 the Dutch health system was a hybrid system based on social insurance, combined with a long-standing role for private insurance covering the better-off. Until 2006 the focus of reforms was on the supply side, with rationalization of provision and strengthening of primary care. The 2006 reforms shifted the focus to the demand side, introducing three managed markets for a defined universal health insurance package, plus healthcare purchasing and provision. The government stepped back from direct control of volumes and prices to a more distant role as supervisor of these markets (though planning of medical professionals remains by limiting the number of doctors trained). Both insurers and providers have been consolidating, in part to strengthen their position within the market. Currently, four insurer groups have 90% of the insurance market. The government provides a web site to help patients choose healthcare providers; other independent web sites are also available. Nevertheless, opportunities to make choices during the care process are limited, as is the extent to which patients exercise their notional choice.
Long-term care was reformed in 2015 in order to contain costs (and was the subject of an EU recommendation through the European Semester). Care at home, preferably by informal carers, is now given greater priority over institutional care, which was seen as having become over-used. Municipalities became responsible for social care – and with a reduced budget, on the assumption that locally organized care will be more efficient. Health insurers took over responsibility for home nursing, with district nurses playing a key role in integrating different aspects of care and support.
The Netherlands has a wide range of public bodies in the health field. Some oversee different aspects of the health system, such as the content of the basic health insurance package and care quality (Care Institute Netherlands), and fair competition between insurers and providers (the Dutch Healthcare Authority). Others provide advice and evidence on different aspects of health, including several scientific research institutes such as the National Institute for Public Health and the Environment, which produces four-yearly reports on the state of public health in the Netherlands. The integration of health across all policies is fragmented, although there is increasing interest in the topic at the municipal level.
Most healthcare providers use some form of electronic patient records.All general practitioners (GPs) use an electronic patient record system; this includes an electronic prescription system. However, the national roll-out of an electronic patient record system to interconnect these practice-based systems failed, mainly for reasons of privacy; a more limited system is being implemented in its place.
Healthcare is principally (72%) financed through the compulsory health insurance contributions from citizens, with an additional 13% from general taxation. Adults pay a community-rated premium to their insurer (the government contributes the premium for children), plus an income-dependent premium into a central fund that is redistributed amongst insurers on a risk-adjusted basis. The basic benefits package includes GP care, maternity care, hospital care, home nursing care, pharmaceutical care and mental healthcare. The first €385 (in 2016) must be paid out of pocket, except for GP consultations, maternity care, home nursing care and care for children under the age of 18. Care that is not covered under the basic package can be insured via VHI, such as glasses and dental care.
Health insurers and providers negotiate on price and quality of care, although competition on quality is still in its infancy. For care for which negotiation is not feasible (around 30% of hospital care), such as emergency care (not plannable) or organ transplantation (too few providers), the Dutch Healthcare Authority establishes maximum prices. Healthcare providers are independent non-profit entrepreneurs. Hospitals are paid through an adapted type of diagnosis-related group (DRG) system: Diagnosis Treatment Combinations. GPs are paid by a combination of fee-for-service, capitation, bundled payments for integrated care, and pay-for-performance (focused on issues such as accessibility and referral patterns). From 2015 long-term care is principally the responsibility of municipalities, apart from home nursing (which comes under healthcare) and residential long-term care (which is financed through a specific scheme funded by an income-related levy). This reform has come with a great deal of social unrest, because the reform also includes substantial savings targets, and with greater pressure on long-term care seekers to first try to find a solution within their social network. It remains unclear how this will work in practice and whether the savings targets will be met. ( HiT )