Page 188 - Effective healthcare cost containment policies Using the Netherlands as a case study - Niek W. Stadhouders

Chapter 8
Appendix to chapter 8
Table 8.1: Application of cost containment policies to the Netherlands
Macrobudget
Price limits
Price negotiations
Wage controls
Input price reductions
Access control
Improving appropriateness
Cost sharing
Prevention
Cost containment policy
Reference prices
Application to the Netherlands
Total public health expenditures are prospectively capped under the “Budgettair Kader Zorg” (BKZ) at the start of the cabinet, as part of government regulation called “Zalmnorm”.
Industry agreements on expenditure caps per sector can be seen as a form of sector budget
Sector budget
In the hospital sector, most prices are freely negotiable, although prices of specific treatments (DBC-A segment) are maximised and could be reduced as form of cost containment policy. Furthermore, maximum prices for long-term care could be reduced. Fee schedules have been implemented in long-term care (called ZZPs) and could be implemented as maximum prices to replace the freely negotiable prices in hospital care (DBC-B segment).
Fee schedule
Price negotiations, such as competitive tendering procedures, have been implemented by some municipalities to contract social care providers. Most prices in the Netherlands, even maximised prices in DBC-A segment and LTC, are freely negotiable. Furthermore, the government has been involved in price negotiations for expensive pharmaceuticals.
A reference pricing system, both internal and external, is used for pharmaceuticals in the Netherlands, but could be expanded. Furthermore, personal budgets are prices as 70% of the maximum price for comparable in-kind care.
Wage controls for nursing staff are complicated due to automatic wage adjustments negotiated through bilateral agreements between government and labour associations (called “OVA-convenant”). The government did successfully contain costs of education and public services by controlling wages during the crisis (called “nullijn”). Efforts were made to increase the percentage of salaried medical specialists compared to independent medical specialist groups.
Capital controls
Capital controls were used extensively but were mostly abandoned as part of the 2006 reform.
Purchasing associations between hospitals have been formed to reduce purchasing costs of pharmaceuticals and medical appliances.
Profit controls
Profits are banned in most of the sector, although in some sectors, notably home care, profits are still allowed. Controls on profit margins of pharmaceuticals are uncommon. Access to specialist care is controlled by general physicians (GP gatekeeping), other forms of access controls and rationing are less common for hospital care. In LTC, access is controlled by indication from an independent assessment organisation (Centrum Indicatiestelling Zorg (CIZ))
Capacity control
Capacity controls have been used extensively, but were largely abandoned after the 2006
reform. For few specialised services capacity controls apply (called Wet Bijzondere
Medische Verrichtingen (WBMV)).
Few tools to improve appropriateness are currently used, such as benchmarking, clinical practice variation research, prior authorisation or utilization review. Insurers (and government) may readily implement these policies
Labour restrictions apply for medical specialists by limits on the number of student places (called numerus fixus).
Cost sharing is used to reduce the public share of costs but not to reduce total costs or to improve appropriateness (see introduction and below).
Benefit package restrictions are used marginally and with limited success. For example, in 2012 physical therapy for certain conditions and dental care between 18 and 23 was excluded from the mandatory benefit package.
Prevention is a small part of total expenditure under separate legislation (called wet publieke gezondheid, Wpg). Municipalities are mainly responsible for prevention and health promotion.
Labour restrictions
Benefit package
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