Funding of curative mental healthcare
An audit of the funding of curative mental healthcare. More than a million people in the Netherlands receive mental healthcare every year at a cost of about €4 billion. Regulated market forces were introduced in 2008. We investigated whether the current model of outcome funding was working as intended. We also considered whether the changes proposed for the funding model could remove obstacles.
Conclusions
The introduction of outcome funding has increased the information available on curative mental healthcare.
Outcome funding has revealed how many people receive mental healthcare, what illnesses are treated and how much the treatment costs. This information will help care insurers and care providers make concrete agreements on the type and amount of care that is provided.
Negotiations on the care market are directed chiefly at controlling expenditure and are not yet based on the quality of care providers.
Outcome funding cannot be effective unless information is available that allows comparisons to be made between care providers and the quality of their care. The absence of this information is an important reason why outcome funding has not yet generated the dynamism sought for the mental healthcare market.
The Minister of Health, Welfare and Sport and the organisations concerned have high expectations for the new outcome funding model.
The Minister of Health, Welfare and Sport wants to make changes to the outcome funding model in 2019. To do so, care standards must be ready for implementation by the end of 2017 and a new product structure must be in place by the beginning of 2018 so that care can be purchased in 2019. The parties have a great deal of confidence in the chosen timeline but it is uncertain whether it is feasible.
Recommendations
Take the time necessary to introduce a coherent and effective funding model.
Getting the many players active in the sector to agree on acceptable standards and indicators for the quality of mental health will be a challenge. The standards must match the healthcare professionals’ quality expectations. The care standards should not be set in isolation but agreed with actors outside the curative care sector in order to be of benefit to the patients.
Decide what accountability information is necessary for the new funding model on time.
The accountability information that care providers must furnish in the new funding model must be consistent with the agreements in the care standards and with the care clusters in the new product structure. A timely decision must be taken when the 2019 funding model is worked out on the information that care providers must provide to care insurers and how it will be audited.
Recognise the difficulties in measuring and comparing outcomes.
There are limits to the ability to measure mental healthcare outcomes using objective indicators. If a patient has complex problems, the outcomes of treatment are not due solely to the healthcare provided but also to other factors such as housing and employment. It is often necessary for several parties in the social domain to work with each other in order to help patients with complex illnesses. The improvements in a patient’s health cannot be ascribed to one particular care provider. There is therefore a risk that a substantial proportion of the expenditure in the funding model will not coincide with the treatment provided.
We recommend that the Minister of Health, Welfare and Sport have the National Health Care Institute express an opinion on the quality of the new quality indicators.
We think it is important that the minister and the parties concerned are aware of the limitations of the Routine Outcome Measurement system and the indicators based on it. The sector must not waste time collecting information that ultimately is of little relevance to the funding model.
Take the time necessary to refine the outcome funding model and give the parties in the field enough time and freedom to gain experience with the 2019 funding model before agreeing a realistic timeline to roll it out.
The new care standards and revised product structure will have an enormous impact in the field. Both care providers and care insurers will have to learn as they go how indicative the care standards are and what information can be used to make comparisons between care providers. It is also still uncertain whether it will be possible in all cases to establish a link between a patient’s care needs, the treatment received, the care outcome standards and the funding.
We recommend that the Minister of Health, Welfare and Sport encourage the parties in the field to experiment with new forms of contract and apply the lessons learned in the further development of the funding model.
On the initiative of the care insurers and care providers, experiments are being carried out to make concrete purchasing agreements instead of setting financial ceilings, and to take a new approach to the negotiation process. These initiatives seem to have arisen from the mutual wish to improve the match between funding and healthcare quality.
Background
Why did we audit the output funding model in the curative mental healthcare sector?
The curative mental healthcare sector treats more than a million people with, for example, depression, an addiction or dementia every year. In recent times, the care has cost about €4 billion a year. Since the introduction of outcome funding, many mental healthcare institutions have had problems preparing their annual reports and financial statements. We looked into these problems in our audits of central government in 2014 and 2015 (Netherlands Court of Audit, 2015 and 2016a). We found that accounting problems in the curative health sector were due largely to the complexity of the funding model. This is why we decided to take a wider look into funding in the curative mental healthcare sector.
Methods
What methods did we use to audit outcome funding in the curative mental healthcare sector?
For this audit, we studied the main policy documents on the introduction of outcome funding in the mental healthcare sector in order to understand the underlying policy theory. We then determined how outcome funding should contribute in theory to the dynamism on the healthcare purchasing market and how it contributed in theory to the quality and efficiency of the care provided.
We used a variety of methods to determine how the funding model worked in practice. We made extensive use of surveys of the mental healthcare market carried out by the Dutch Healthcare Authority. The Healthcare Authority collects data on the market in order to report on developments in mental healthcare twice a year. It also has the most recent figures on patient numbers, waiting times, diagnoses and expenditure. We also drew on evaluation studies regarding the implementation of the Care Insurance Act.
We held interviews with staff at key organisations to discuss the funding of mental healthcare. At the end of the data collection phase, we organised a seminar with key figures in the field.