The “Health Benefit Basket” in The Netherlands

The ZFW specifies a general entitlement to specialist care by hospitals (both inpatient and outpatient care): patients are entitled to medical, surgery, and obstetric care. Entitlement to hospital care also exists under the AWBZ if the patient must stay in hospital longer than 365 days. The provided care is limited merely by professional norms following the “usual care” principle (appropriateness according to professional standards). Also, a general statement is made that health care should be provided efficiently. Therefore the definition of entitlements for hospital care is rather implicit and the “usual care” criterion is not very restrictive. However, the entitlements are conditional upon the referral by a general practitioner, by another specialist to whom a general practitioner had referred the insured, or, where obstetric care is concerned, by a midwife.

A ministerial decree, the Regulations on Medical Specialist Care, further specifies entitlements by excluding specific forms of transplantation and plastic surgery. It also determines that only certain types of transplantations are covered, and states that entitlement to some services (e.g., plastic surgery) only exist if specific conditions are met. Finally, this regulation explicitly excludes services such as eyelid, ear or body sculpturing, in vitro fertilization (IVF), uvoloplasty for persons who snore, sterilization or undoing sterilization, and circumcision. It should be noted that IVF is a special case and its reimbursement policy changed several times. Today, health insurers are subsidized to fund IVF treatment for the insured after the first attempt has been paid out of pocket.

Pharmaceuticals dispensed in hospitals are part of the entitlement to hospital care. They are generally financed out of the hospital budget, but the insurer may separately reimburse an additional percentage (up to 80%) of the cost for very expensive hospital drugs.

The law remains rather vague about entitlements to hospital care, but a recently introduced pricing system has led to more explicit benefit definition. In 2005 a new system for hospital financing was introduced by law: the Diagnose Behandeling Combinaties (DBCs), a DRG-like system describing all products that are provided in hospitals. Medical experts were involved in the determination of these DBCs, which are defined as the whole set of activities (diagnostic and therapeutic interventions) of the hospital and medical specialist starting from the first consultation and diagnosis of the medical specialist in the hospital until discharge. Each DBC is characterized by a code combining information on diagnosis (International Classification of Diseases, 10th edition) and treatment. This system facilitates negotiations between health insurers and hospitals on prices (on a bilateral level), at the same time providing a catalogue of medical services. Table 2 shows how many different DBCs are defined within a medical specialty distinguishing between list A (prices fixed by the National Health Tariffs authority until further notice) and list B (prices negotiated by Sickness Funds and hospitals from January 2005 onwards). This catalogue of DBCs allows the specification of which DBCs are included in the basis package: the “red” list presents the number of DBCs not covered by compulsory insurance as determined by the Health Care Insurance Board on the basis of the “usual care” criterion and current explicit exclusions. Also an “orange” list exists with DBCs for which reimbursement is limited to certain groups of patients. Finally, the table lists the number of product groups that have been defined to cluster DBCs into homogeneous price groups, as negotiation on the price of each single DBC would not be feasible.

An exception to the way in which medical specialist services are regulated is mental health care, which is currently covered under the AWBZ. Also the first year of treatment is covered by the AWBZ and not by the ZFW, as is the case for other medical specialist services. The reason is that psychotherapy is often a long and intensive treatment. Ambulatory psychotherapy is reimbursed (maximum of 25 sessions, 50 in the case of personality disorders) if referral is by a general practitioner or psychiatrist. Patients’ entitlements to mental health care through the AWBZ include treatment (therapy sessions and medication), supportive guidance, and accommodation. Special regulations apply to mental health care in children and to treatment of addictions. The objective is to make mental health care a part of the basic benefit package under the new Health Insurance Act and therefore shift it to compartment 2 in a competitive environment. To permit this change DBCs in mental health care are now being defined.

Primary care, i.e., medical and surgical care provided by general practitioners, is covered under the ZFW, as specified in the Health Insurance (Treatment and Services) Decree. Care involves mainly consultations and visits, the prescription of pharmaceutical care, referral to medical specialists, and minor operations. Entitlements to these services are also defined implicitly: any type and quantity of care consistent with professional norms is covered by the scheme.

Entitlements to dental care have been limited in the past and are defined explicitly. The ministerial regulation “Dental Care Health Insurance” stipulates that persons up to the age of 18 years are entitled to dental care under the ZFW. Dental care includes 14 types of services, among which are periodic checkups, fluoride application treatment, sealing, and periodontal care. Adults are entitled to dental care only under special circumstances: special dental conditions and physical or mental disabilities.

Paramedical care—consisting of physiotherapy, Mensendieck or Cesar remedial therapy, speech therapy and ergotherapy—is partly covered. The first nine sessions are excluded from reimbursement, but thereafter some patients over the age of 18 years are entitled to physiotherapy, Mensendieck or Cesar remedial therapy for the treatment of chronic conditions that are defined in the Regulations Governing the Provision of Paramedical Assistance.

Under exceptional conditions and with authorization by the sickness fund, specialized services of curative care may be provided at home. First, persons are entitled to kidney dialysis at home or in a dialysis center under ZFW. If the dialysis takes place at home, the costs of training a person to carry out dialysis or providing assistance during the procedure are also covered. The costs of inspecting and maintaining equipment, modifying the home, providing special sanitary fittings, and heating are also reimbursable. Second, the ZFW regulates the use of treatment for chronic intermittent ventilation. Those covered by the ZFW are entitled to treatment at a ventilation center. A center may lend the patient the equipment for use at home or in a location where several persons can use the equipment. Specialist and pharmaceutical care provided by or on the advice of the ventilation center are also included.

In The Netherlands decisions about the medical services offered to a patient are often left to the physician (and/or the health insurer). Negative lists are in certain categories used to exclude services (e.g., the new red and orange lists of DBCs). The extent to which new or old technologies (therapy, diagnostic services, and pharmaceuticals) are provided to the patient in the context of a DBC is left to the providers. However, some medical services were explicitly excluded for not being considered to belong to the domain of health care (e.g., plastic surgery). Additionally, limits were set to the provision of physiotherapy and psychotherapy for a lack of demonstrated effectiveness. Restrictive legislation only exists in the pharmaceutical sector where an itemized positive list of individual products is frequently updated [4]. For several other functional categories there are also positive lists, but these are not frequently updated (e.g., for medical devices and vaccines). Regarding pharmaceuticals it is interesting to observe that the reimbursement of extramural drugs (prescription filled by the community pharmacist) is centrally regulated, while for the use of drugs in the hospital the policy is liberal. The liberal policy has led to wide variations in the availability of certain expensive drugs across hospitals and to referral of “expensive” patients to specialized centers. The new hospital financing system will change this and will probably force decision makers to regulate the provision of expensive drugs within a DBC.

The package can be limited by management of positive or negative lists, copayments, the definitions of conditions restricting eligibility, and promoting best practice, i.e., effective and efficient provision of care. Each instrument is applied within the Dutch system, although some sectors are more loosely managed than others. On the whole, emphasis is put on offering incentives for efficiency. Recently a no-claim system was introduced: if someone insured under ZFW has no expenses, he receives a bonus of €255 from his insurer or the difference if his expenses are less than €255. The liberal character of the basket is further illustrated by the fact that there is no systematic and central effort to use common criteria for defining the package as a whole. Nonetheless, decisions tend to be guided by a quite homogeneous set of considerations.

The respective Ministers of Health and more specifically the Health Care Insurance Board have been using health technology assessment (and cost-effectiveness information) since the middle 1980s as a tool for deciding on large public programs (e.g., national cancer screening programs) and on the addition of expensive curative programs (e.g., transplant programs) to the package [5]. Especially in the case of pharmaceuticals dispensed outside the hospitals the role of cost-effectiveness as criterion for reimbursement is quite prominent. If the manufacturer can demonstrate greater effectiveness than existing drugs and wants a premium price, he must submit a pharmacoeconomic dossier and figures allowing the Health Care Insurance Board to base its policy on information on (cost-)effectiveness.

Furthermore, many technology assessment studies have been financed from a special fund managed by the Health Care Insurance Board and later by the National Medical Research Council that have produced valuable information on the cost-effectiveness of new diagnostic and therapeutic procedures. Although not legally required, this information has been used to define the benefit package or for the development of practice guidelines.

Further criteria have emerged as constant factors in decision making: severity of illness, individual vs. collective responsibility, affordability, and leakage (the probability of use outside a targeted patient group) [6]. Although initially consistent use of these criteria may have been doubted, gradually patterns emerged. Severity of illness, for example, played a role in deciding to finance the lung transplantation program although it was demonstrated to have a high cost-effectiveness ratio [7]. In relation to budget impact it also played a role in the decision not to fund PDE-5 inhibitors in the treatment of erectile dysfunction. Responsibility and affordability have played a role in deciding to restrict the reimbursement of pills for minor illnesses and dentistry. Leakage played a role in the decision to limit funding of some medicines (e.g., clopidogrel) to specific patient group. The increased understanding of the balance between the criteria is also recognized by policy makers.

An important way to influence the providing of service is through practice guidelines. There are many disciplinary and interdisciplinary practice guidelines for both primary and secondary care, some of which are also based on economic evidence. In The Netherlands a government program supported the development of practice guidelines in 1998–2002 which led to 31 consensus guidelines for medical practice addressing 23 disorders across seven disease groups as defined by the International Classification of Diseases. One example is the guideline for the use of cholesterol-lowering drugs in primary and secondary prevention which sets rules for the prescription of statins according to the patient’s personal risk profile.

An important development is the change in hospital financing, involving description of the benefit package in terms of DBCs which are or are not reimbursed. Currently it is being discussed how the definition of DBCs can be more detailed to include specific regulations on the technologies to be used within a certain treatment. A so-called “maintenance organization for DBCs” is set up to (re)define DBCs.

The reforms of 2006 are intended to reduce government control in the health care sector and provide incentives to patients and insurers for cost consciousness. Health care should follow the preferences of consumers. It follows that entitlements are formulated in functional form rather than as specific facilities or services. It is still not clear whether local actors will assume a role in defining the basket, and whether the government will centralize decisions.