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Public reporting and accountability

The Dutch case

Gert WestertProfessor of Health Services Research, Radboud University Nijmegen Medical Centre; Head DHCPR, National Institute of Public Health (2006 – 2011)

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Dutch health care: brief history Untill 1940: no government regulation with respect to health

insurance: private initiatives 1941: mandatory public health insurance for low- and middle

income groups 1970-1985: Pressure on central goal: universal access,

government plays important role• 1980s focus on control of costs• 2000: awareness of side effects of supply-side regulation, focus

on quality. New paradigm:• From supply-oriented to demand-oriented (patient-centered care)• More important role for health insurers• More room for providers• Efficiency through managed competition

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Context: regulated competition

Dekker – report (CEO Philips); 1984

“The Dutch government believes the performance potential of the health care system can be substantialle boosted if centralised state control makes room for a decentralised system of regulated competition” (Ministry of Health, 2004)

2006 New Health Insurance Act

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“More market elements” Consumers (18+) have to take out private insurance and

receive a government defined health insurance package (broad and deep)

Insurers are obliged to accept all applicants Health insurers compete, and critically purchase services

from providers Providers will provide “more for less”, in terms of access,

quality, costs

Government takes backseat; Less “controlitis” and central planning, increasing competition Speed up technical and organizational innovations Increase responsiveness

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Regulated competition Dutch Health Care Authority (Nza) controls the right

functioning of the three markets Health Care Inspectorate (IGZ) sets quality and safety

standards Health Care Insurance Board (CVZ) advises on the cost-

effectiveness of the insurance package (too broad, too deep?)

MoH responsible for access, quality, costs, but operates at distance

Website to support citizens (Kies Beter/ Choose Better) Indenpendent researchers monitor (un)intended effects

and change: DHCPR

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Public Reporting Performance assessment

Public Health Status and Forecasts report State of Public Health Since 1993, fifth edition

2010, next 2014

Health Care Performance report State of Health Care Since 2006, third edition

2010 (May), next 2014

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DHCPR Commisioned by MoH; independence?

Target group: Dutch citizens, represented by members of Parliament

Describe access, quality and costs of healthcare system (prevention – cure and long term care)

Use limited number of macro indicators (150) Time series comparisons International comparisons Regional variations/ benchmarking Patiënt perspective Focus on outcomes

Pay attention to: efficiency, effect of reforms

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From assessment to action

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DHCPR: used? Bridging the gap between science and policy is

…”it isn’t love at first sight” MoH prefers more than one source (partner)

Send to Parliament by MoH Use all sources available and summarize Provide key messages and an executive summary Provide a research agenda (Chapter 6: Towards

the next … Stick to your role: evidence and science Keep in mind: healthcare is about value for

patients

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Issues to discuss What makes this urgent in the Australian

context? Accountability issues.

What needs to happen in Australia to get PR established? Barriers and enablers.

Role of Independence and engagement all stakeholders.

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lunchbreak

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Does it work, the Dutch model?

Most important issues 2013:

Access is good, quality varies Insurers tend to contract on (total) price and less

on quality, but license to operate is at stake … System is focussed on volume of healthcare; shift

towards value for patients needed Expenditure growth not sustainable … 14% GDP Transparancy and quality information: opaque, but

improving, focus on outcomes

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Healthcare reforms 2006

Health expenditures percentage GDP

Expenditure growth not sustainable14% GDP

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Does this work (in a period of economic downturn)?

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Dutch GP’s: 59 percent state that patients receive too much care

IHP 2012, Commonwealth Fund

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“For a few dollars more”: well spent? Waiting lists (2001): ∨ Hospital productivity: ∧ Life expectancy ∧

Pay for volume

Elderly use more services, lower mortality

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Is this too much or value for money?

• No waiting lists: overtreatment?• Expenditures up: price and volume issues (cataract

surgery)• Practice variation huge, but invisible (IQ healthcare,

2012)• GPs and hospital physicians: “live in separate worlds”

Separate budgets and income schemes induce overdiagnosis and - treatment

GP per enrolee/ service (60/40); Hospital (physician) paid fee for service/ volume

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What’s next• Government: expenditure / hospital volume growth

restricted (2.5%)• Out-of-pocket 50 EURO for visit ER (bypassing the GP)• 350 EURO deductible for hospital care• Tracking unnecessary or unwarranted care (20 – 35%)• TRANSPARANCY: how much we spend; what we spend

our money on (activities) and what the outcome for patients is, but … disruptive

• Nobody really wants to know: payer, provider, politicians caught in a trap >>> patients can help

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Utilisation (VOLUME)?Expenditures? Outcomes (VALUE)?

Geographic perspective

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Dutch Atlas of Health Care Variation:Elective surgery

1. Huge variation in activities (pilot)2. What is the price of activities at local level?3. What is the value for patients? We don’t know? Need to measure outcomes

Back hernia,CTSProstateGallbladderVaricose veinsTonsillectomiesCataractKnee replacements

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http://praktijkvariatie.depraktijkindex.nl

The Federation of Patients and Consumer Organisations in the Netherlands (NPCF).

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http://praktijkvariatie.depraktijkindex.nl

“We have a problem”

Neurosurgeon presented to colleagues (Wilco Peul): back hernia surgery

Factor 3 to 4 between catchment areas

Response “brothers in arms”

Data isn’t right Data maybe right, not my problem My patients are different

Let’s take a look

Uitspraak

“50% van de zorg die wij bieden is onzin, we weten alleen niet welke 50%” (oncologe)

Why?

Medical uncertainty is huge 50% is effective We see more, but far less important

things Professional autonomy (in isolation) Cookbook medicine Art and improvisation versus scientific

approach

What is definitely wrong We pay for “income”, not for outcome Quantity dominates quality Doing dominates“watchfull waiting” More is better >>> Less is more

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2Categorize care in 3 categories

Effective care: 25%

Preference-sensitive care: 25%

Supply-sensitive care: 50%

3 Signal practice variation on map

(utilisation, costs, outcomes)

Use these signals to get stakeholders in a room (lock the door)

4 Shared decision making: the silent

misdiagnosis

T = f(Md, Pd)

Doctor and doctor

Thesis

Most of the time we do things good, but are we doing the right thing?

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Further reading

www.healthcareperformance.nl

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Questions?

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Le$$

Thanks

Gert Westertg.westert@iq.umcn.nl

Let’s collaborate; we needmore fingers for our dykes!