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Exhibit ES-1. Key German and Dutch Policies for a Multipayer System, with Insights for U.S. National Reforms. Insurance Markets Insurance exchanges with insurance market rules/reforms Prohibition on health risk rating; community rating Value-based insurance benefit design and pricing - PowerPoint PPT Presentation


  • Exhibit ES-1. Key German and Dutch Policies for a Multipayer System, with Insights for U.S. National ReformsInsurance MarketsInsurance exchanges with insurance market rules/reformsProhibition on health risk rating; community ratingValue-based insurance benefit design and pricingRisk equalizationPayment coordination and use of group purchasing power in public interestComparative effectiveness to inform value and pricesPublic reporting, benchmarks, and incentives for quality

  • Exhibit 1. International Comparison of Spending on Health, 19802007Average spending on health per capita ($US PPP*)Total expenditures on health as percent of GDP* PPP=Purchasing Power Parity. ** All 30 OECD countries except U.S.Source: OECD Health Data 2009, Version 06/20/09.$7,290$3,837$3,58816.0%10.4%9.8%

  • Exhibit 2. Mortality Amenable to Health Care, 2002/2003U.S. Rank Fell from 15 to Last out of 19 CountriesDeaths per 100,000 population ** Countries age-standardized death rates before age 75; from conditions where timely effective care can make a difference including: diabetes, asthma, ischemic heart disease, stroke, infections, screenable cancer. Data: E. Nolte and C. M. McKee, Measuring the Health of Nations, Health Affairs, Jan/Feb 2008).Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

  • Exhibit 4. The Netherlands and Germany Health Care Triangle: National Leadership Central

    GovernmentZorgaanbiedersCare ProvidersPatientsInsurers

    Source: Adapted from presentations to AcademyHealth Netherlands Health Study Tour on Sept. 22, 2008, The Position of the Patient and Healthcare Quality.Choice Choice COMPETITION AND COLLABORATION Insurance Market Payment Quality Information

  • PopulationProvidersSocial health insurance: 90%Private health insurance: 10%Publicprivate mix, organized in associations ambulatory care/hospitalsChoice of insurancePayment contracts, mostly collective negotiationDelegation and limited governmental controlInsurersSocial insurance (~200 sickness funds) and private (~50)Choice of providerSource: Reinhard Busse, Berlin University and European Observatory. Presentation to The Commonwealth Fund, 2008.Exhibit 5. The German Insurance System at a Glance

  • 8.2%7.3%Exhibit 6. German Federal Health Insurance Fund: 2007

  • Exhibit 7. Oversight of the German Health Care SystemGerman Federal Ministry of Health: Legal framework, planning, supervision, accreditation, commissioning, and enforcementFederal Joint Committee: Core of self-regulatory structurecomposed of insurer, provider, and neutral representatives; patients participate with advisory roleissues legally binding directivesdefines sickness fund benefit packageInstitute for Quality and Efficiency in Healthcare (IQWiG): Comparative/cost effectivenessFederal Health Insurance Fund: Risk equalizationFederal Office for Quality Assurance: Hospital quality indicators, benchmarks, and feedback

  • Federal Ministry of HealthRegulation & supervisionPatientsFederal Association of SHI PhysiciansAll 414,000 physiciansGerman Hospital Federation2,100 hospitalsFederal Association of Sickness FundsFederal Joint Commitee (G-BA)Institute for Quality and Efficiency in Healthcare (IQWiG) (technologies)Institute for Quality (providers)Statutory Health InsuranceFederal Physicians Chamber190 sickness fundsSource: Richard Busse, The Health System in GermanyCombining Coverage, Choice, Quality, and Cost-Containment, PowerPoint Presentation, 2008. Updated April 13, 2009.150,000 physicians and psychotherapistsExhibit 8. Health System in Germany

  • Exhibit 9. National Quality Benchmarking in GermanySize of the project:2,000 German hospitals (> 98%)5,000 medical departments3 million cases in 2005 20% of all hospital cases in Germany 300 quality indicators in 26 areas of care800 experts involved (national and regional)Source: C. Veit, "The Structured Dialog: National Quality Benchmarking in Germany, Presentation at AcademyHealth Annual Research Meeting, June 2006.Ideas and goals: define standards (evidence based, public) define levels of acceptance document processes, risks and results present variation start structured dialog improve and check

  • Exhibit 10. National Leadership Oversight Within the Dutch Health MinistryThe Dutch Health Insurance Board: risk equalization fund and comparative effectiveness/benefits (acute and long-term).The Dutch Health Care Authority manages competition; prices and budgets; transparency.The Dutch Health Care Inspectorate supervises the quality of the care.The Dutch Competition Authority prevents cartels, authorizes or forbids mergers, and prevents the abuse of a dominant market position.

  • Exhibit 11. Dutch Risk-Equalization System: Each Adult Pays Premium About 1,050 Euros AnnuallySource: G. Klein Ikkink, Ministry of Health, Welfare and Sport; Presentation to AcademyHealth Netherlands Health Study Tour on September 22, 2008, Reform of the Dutch Health Care System.

    In Euros per yearWoman, 40, jobless with disability income allowance, urban region, hospitalized last year for osteoarthritisMan, 38, employed, prosperous region, no chronic disease and no medication or hospitalization last yearAge/gender 934 872Income 941 63 Region 98 67Pharmaceuticalcost group 315 315Diagnostic cost group 6202 130From Risk Fund 7800 297

  • Exhibit 12. Benchmarking in the Netherlands

    ***Then we look at the system such as it should work out in the end.

    In short, we strive after a healthcare system that is demand or pull oriented.

    In the end, in the Dutch healthcare: * Healthcare providers: Responsible for quality, transparency, responsible for investments, higher risk profile* Healthcare insurers: Negotiations with healthcare providers on price, volume and quality* Patients: Freedom of choice, information to select available, influence on healthcare providers and insurance companiesLastly, the role of government will be restricted to making the system work. To laying down the rules for the interactions between providers, insurers and patients, and to refrain from interfering in those interactions.


    De clint zal de geleverde zorg steeds meer beoordelen aan dehand vna zijn ervaringen met de zorg en de professionele kwaliteit. Transparantie op deze terreinen zal voor de patint steeds crucialer worden.De verzekeraar zal het begrip kwaliteit steeds meer gaan invullen langs de parameters doelmatigheid, beoordeling van de zorginhoud en het zorgproces en de wensen van de clint daarbij. De verzekeraar zal zich in de markt willen onderscheiden van andere verzekeraars door aan te geven dat hij de beste zorg contracteert voor zijn klanten.De zorgaanbieder zal het begrip kwaliteit invullen langs drie dimensies:leveren van zorg naar de meest recente professionele inzichtensteeds meer transparant zijn over de geleverde prestatiesstreven naar kwaliteit steeds meer financieel beloond.Overheid is verantwoordelijk voor de ontwikkelingen van de wetgeving en het stellen van de kaders waarbinnen de zorgaanbieder zich dient te bewegen.

    *Wie hoch ist tax revenue?Gesellschaftl. Lst.Stufenmodell: 2008: 1,5 Mrd. 2009: 3 Mrd. bis 16 Mrd insgesamt????

    **WB Vienna 30may08 Netherlands***Example of a quality report for a specific home care institute, based on CQI data.

    We have currently studied the optimal presentation format for consumers (with respect to effective use and interpretation):In general, formats using three stars, an alphabetical ordering of providers, and no inclusion of a global rating support consumers best in their interpretation and choice. This format was developed in an earlier phase and obviously needs to be readjusted. But: research is not the only stimulus and sometimes stakeholders insist to present 5 star ratings.


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