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
ZIN SW&P ZIN = Healthcare Institute Netherlands decides about SWP, based on PICOT, EBM and GRADE process à To be reimbursed
ZIN SW&P NZa = Dutch Healthcare Authority NZa • Code • Tariff: free fixed max
WMO WLZ ZVW ZIN SW&P NZa
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
WMO WLZ ZVW Health offices ZIN SW&P NZa
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
WMO WLZ Municipalities ZVW ZIN SW&P NZa
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
WMO WLZ ZVW Achmea CZ Menzis ZIN SW&P VGZ Other NZa
Competition in health care 4 insurers covering more than 40 labels
HIC (Health Insurance Companies): HIC HIC Patient Healthcare Patient provider 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, occupational 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 of 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) Reimbursement Care activity/care product yes Code? no opportunity Application with NZa WV PO (scientific (patient ZIN organization) organization) Reimbursement no yes EBM? opportunity 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 experimental ZIN HIC ZIN or HIC =SWP No ZVW VT BI (Guideline (CED) for Innovation) RH
Recommend
More recommend
