Ov Overview re regulations Dutch ch he healthc thcare Health - - PowerPoint PPT Presentation

Ov Overview re regulations Dutch ch he healthc thcare

• Health insurance act (zorgverzekeringswet): responsability of Health

insurance companies

• Long term care act (WLZ): responsability Zorgkantoren (Health offices)
• Social support act (WMO): responsability Municipalities
• Additional insurances: responsability of the consumer to avoid out of

pocket payments

Ov Overview re regulations Dutch ch he healthc thcare

• As a start: in general:
• Investment goods are to be paid from the budget and is the

responsability of the Hospital, the Nursing Home, the GP practice, the dental practice etc

• Products related to an individual person must be paid on the basis of

a regulation and therefore part of a reimbursement system

SW&P

SWP = Standard of care and daily practice

SW&P ZIN

ZIN = Healthcare Institute Netherlands decides about SWP, based on PICOT, EBM and GRADE process à To be reimbursed

SW&P ZIN NZa

NZa = Dutch Healthcare Authority

• Code
• Tariff:

free fixed max

SW&P ZIN NZa WMO WLZ ZVW

ZVW (Health Insurance Act): Compulsory basic insurance package. Government decides about nature, content and scope. Average cost €1,218 per year + income-based contribution of 6.75 % over a max. of € 52,763 17 mio people: 70 % in collectivities 30 % non-collectivities Policies: 50 % budget in kind 20 % mixed 30 % reimbursement Each year about 7 % (1.1 mio people) changes from one health insurance to another 84.1 % has supplementary insurance

SW&P ZIN NZa WMO WLZ ZVW Health offices

WLZ (Long-term Care Act): the most serious long-term care Income-based contribution of 9.65 % over a max. of € 33,589 WLZ is executed by (32) regional health offices

SW&P ZIN NZa WMO WLZ ZVW Municipalities

WMO (Social Support Act): covers all kinds of social support, including medical devices related to well-being and participation in society Executed by municipalities, about 380 Funded from local taxes Municipalities use tenders for the WMO

SW&P ZIN NZa WMO WLZ ZVW Achmea CZ Menzis VGZ Other

Competition in health care

4 insurers covering more than 40 labels

HIC (Health Insurance Companies):

HIC Patient Healthcare provider HIC Patient Healthcare provider Budget-in-kind Reimbursement

Ov Overview re regulations Dutch ch he healthc thcare

• Package criteria Health Insurance Act: these are the 5 relevant

questions

• 1. Is there a health problem that "matters"?
• 2. Is there a "solution" for that problem that really works?
• 3. Are the costs of that solution in a reasonable relation to the health

gain to be achieved?

• 4. Can not these costs be paid by a patient himself?
• 5. Can society do this?

Basic c pack ckage Health Insurance ce Act ct

• Medical care, including from General Practitioners (GPs), hospitals, medical

specialists and obstetricians

• Time spent in hospital
• Dental care (for under18s; only specialist dental care and dentures for

those aged 18 and above)

• Medical devices
• Medication
• Maternity care
• Patient transport (ambulance and seated transport)
• Paramedical care (limited physiotherapy/remedial therapy, speech therapy,
• ccupational therapy, dietary advice)

WL WLZ Z (L (Long ng-te term care act)

• vulnerable elderly
• disabled people
• in need of permanent, full time care or continuous

supervision

• unable to live independently in their own home with support

from their social network, municipality or with home care

WL WLZ (Long-term care act ct)

Indication for long term care is expressed in a care profile (nature, content and broad scope) Room for customization. Care profiles categories:

• Sector Nursing and Care
• Sector Mentally retarded
• Sector Slightly mentally retarded
• Sector Physically handicapped
• Sector Sensory disability, auditory and communicative
• Sector Sensory handicapped, visually
• Sector Mental health, group B

WM WMO (Soci cial Support Act ct)

• Municipalities responsible for support of citizens with limited ability to

participate.

• Should lead to people being able to live at home longer and to participate

in society. (improve sense of well-being and prevent unnecessary medicalization and associated cost)

• Budgets involved to be used by municipalities. Municipalities have great

freedom at organizing customized support.

• In return for support offered municipality expects citizens to do their best

to participate, both socially and financially.

• Municipalities often have contracted parties that can offer whole package
• f care and support. For these contracts procedures for a European tender

are being followed.

WM WMO (Soci cial Support Act ct)

• General services (shopping service, meal service etc.)
• Customized support (domestic help, home adjustements etc.)
• Transport services (Wmo-taxi, mobility scooter, wheelchair etc.)

Ca Care e fo for the the el elder erly:

Nursing homes

• 2433 nursing homes
• ± 80.000 people staying in nursing homes

Home care

Re Reimbursement

• Hospital care
• Medical devices out-patient

Ho Hospit pital al ca care

DBC care products

• Care activities, according to existing rules for registration
• Differentiation based on chapters and sub chapters within the ICD-10.
• The whole of care activities provided by a care provider concerning the care demand of the

patient.

• Each DBC care product has a code, which determines the maximum tariff
• Actual fee is negotiated by care provider and health insurance company

Other care products

• Four categories, sub categories
• Supplementary care products (add-ons)
• First line diagnostics
• Paramedic treatment and examination
• Other performances

Medical device (+ CE) Code? no yes Care activity/care product Application with NZa ZIN WV (scientific

• rganization)

PO (patient

• rganization)

Reimbursement

• pportunity

EBM? yes no Reimbursement

• pportunity

Options:

• 1. Wait for evidence
• 2. Institution budget

(hospital)

• 3. Case by case

(Hosp. + HIC)

• 4. Guideline for innovation

(Hosp. + HIC + Nza)

• 5. Conditional admittance

(WV, ZonMW, PO, ZIN, MOH, HIC)

Reimbursement of medical device ces extramural

• Prescribed by GP: can be reimbursed when this device belongs to a

category in the Medical Devices Act.

• Prescribed by medical specialist:
• 1. To be paid for by the hospital when used in the hospital
• 2. To be paid for by the hospital when used in home situation while

patient remains under treatment of the medical specialist

• 3. To be paid from the Medical Devices Act when the patient no longer

remains under treatment of the medical specialist.

Introduction of new devices outpatient market (innovation)

CE Me-too RH Not me-too EBM No EBM ZIN or HIC =SWP RH ZIN HIC VT (CED) BI (Guideline for Innovation) experimental No ZVW