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111025 kias apria presentation def
1. Healthcare in The Netherlands:
Combining competition and solidarity
Public/private elements for building 21st century healthcare
KIAS – APRIA – International Symposium on Health Insurance
Seoul, 03 November 2011
Piet de Bekker
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. 1. Private Health Insurance:
The Michael Moore effect
KIAS APRIA Symposium | 03-11-2011 3
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 years
prior to 1999. No statistical tests are conducted between 2005 and 2006 due to the addition of HDHP/SO as a new plan
type in 2006.
Note: Information was not obtained for POS plans in 1988. A portion of the change in plan type enrollment for 2005 is
likely attributable to incorporating more recent Census Bureau estimates of the number of state and local government
workers and removing federal workers from the weights. See the Survey Design and Methods section from the 2005
Kaiser/HRET Survey of Employer-Sponsored Health Benefits for additional information.
KIAS APRIA Symposium | 03-11-2011
Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2011; KPMG Survey of Employer-Sponsored 4
Health Benefits, 1993, 1996; The Health Insurance Association of America (HIAA), 1988.
5. There is an alternative …
KIAS APRIA Symposium | 03-11-2011 5
6. Agenda
1. Private Health Insurance – the Michael Moore
effect
2. Health Systems in Europe: public and/or private
3. Netherlands: the basics
4. Health System in The Netherlands
5. Recent Health Insurance reforms
6. Towards sustainable healthcare through
effective competition
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7. 2. Health Systems in Europe
Three basic models of health financing
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8. Beveridge: state-run and tax-funded national
health service providing free-of-charge
healthcare services for the entire population
through mainly publicly-owned facilities and
salaried staff.
Beveridge:
-Tax
-Government
-Public service
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9. Semashko: centrally-organised and state-financed health
service in the former socialist countries with publicly
owned healthcare facilities and different levels of state
administration responsible for planning, allocation of
resources and managing capital expenditures
Semashko:
-Government
-Complete control
-Tight planning
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10. Bismarck: systems of social insurance, funded
out of income-related contributions (pay-roll
taxes) and administered by (semi)-public
sickness funds, ensuring financial protection
against the risk of healthcare costs.
Bismarck:
-(Social) Insurance
-Employers &
employees
-Public-private mix
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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 demand
Source: Journal of Economic Literature Vol. XL (Sept 2002),
pp. 881-906 KIAS APRIA Symposium | 03-11-2011 11
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
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14. 4. Health System in The Netherlands
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15. Some institutional characteristics
1. 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 physician
5. Large general acute-care hospitals; but care is normally
‘around-the-corner’ (GP)
6. Small acute health care sector; large long-term care sector
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17. … and after our reforms
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18. 5. Recent Health Insurance reforms
The 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 adaptation
and ultimately, evolution.
But competition is a means and not a goal…
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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
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20. All OECD countries have achieved universal or near-universal health
care coverage, except Turkey, Mexico and the United States
2007
Source: OECD Health Data 2009, OECD (http://www.oecd.org/health/healthdata).
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. 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
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24. Choice is the driving force
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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)
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26. 6. Towards sustainable healthcare
through effective competition
The system is sown, but the real harvest
has yet to come…
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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)
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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!
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29. Thank you for your attention!
Questions / comments: pietdebekker@zorgvuldigadvies.nl
www.zorgvuldigadvies.nl
KIAS APRIA Symposium | 03-11-2011 29
