Basic health insurance package
Expenditure management in the health care sector part 3
The removal of certain treatments from the basic health insurance package in order to control health care expenditure has so far been less effective than originally thought. The Dutch National Health Care Institute is systematically reviewing the basic package to identify inefficient treatments. In our opinion, this approach provides promising opportunities for more effective package management in the longer term. These findings are presented in our report entitled Basic health insurance package; Expenditure management in the health care sector part 3.
Package management has so far proved less effective than expected as an instrument to manage and reduce health care expenditure.
Limited opportunities for package management
In recent years the Minister of VSW has tried to curb the growth of health care expenditure by means of package management measures that have removed certain treatments from the basic insurance package. On more than one occasion, however, the savings achieved by each individual measure have been less than expected. We estimate that the package measures taken so far have saved about €0.25 billion per annum, half the anticipated saving of €0.5 billion per annum.
Obstacles to implementing positions
Package management also includes the positions taken by the Dutch National Health Care Institute to help control health care expenditure. Various obstacles, however, have prevented the implementation of those positions. Furthermore, it is uncertain whether the positions have democratic and social legitimacy.
Short-term savings uncertain
The National Health Care Institute has introduced strict package management in the form of the Sensible Care programme. In our opinion, this systematic approach to reviewing the basic insurance package to identify inefficient treatments offers promising opportunities to improve package management in the longer term. In view of the savings target set for 2017 (€225 million) we wonder whether the National Health Care Institute should implement the proposed improvements more strictly.
More consideration for appropriate provision of health care
The policy debate regarding the management of health care expenditure has since moved to the appropriate provision of insured health care: not more care than is needed, and not less than is necessary. The Quality Institute, a new part of the National Health Care Institute, has been encouraging the appropriate provision of health care and making it more transparent since April 2014.
Outlook for the further development of package management
In the future, the National Health Care Institute should have no need for a separate Sensible Care programme. Systematic review and monitoring could be integrated into the regular package management measures. At the same time, the improved package management should be combined with the Quality Institute’s activities to create a more coherent approach.
We recommend that the Minister of VWS:
- Have the National Health Care Institute systematically monitor the positons and the measures taken to remove treatments from the basic insurance package. More specifically, evaluate the measures that have the greatest potential financial impact.
- Allow for both the expected and the actual financial consequences of the measures and positions in the Care Financial Picture (FBZ). Share the policy lessons learned with the House of Representatives.
- Clarify whether responsibility and power for the National Health Care Institute’s positions lie with the Ministry of VWS or with the Institute itself.
- Remove the obstacles to implementing the positions.
- Formulate a vision of how the proposed improvements can be made in the Sensible Care programme.
We recommend that the National Health Care Institute:
- Strengthen the effect of the positions in the provision of health care provision.
- Actively promote implementation of the proposed improvements in the Sensible Care programme by parties in the field.
- Work out how package management and the Quality Institute’s activities can complement and strengthen each other. Do not hesitate to use the Quality Institute’s legal powers if parties in the field do not fulfil their role.
Response of the Minister
Response of the Minister of VWS and of the National Health Care Institute
The Minister of VWS agreed with the main points of our conclusion that package management has proved a less effective instrument to control care expenditure than originally intended. The minister has used the government’s current term of office to promote strict package management and has taken a detailed look at which insured persons qualify for specific treatments and which do not. The minister is convinced that this is the best approach to improve the quality of health care and make package management smarter and fairer. He also expects it to make a substantial contribution to savings.
In response to our recommendations, the Minister of VWS noted that the annual report included a qualitative description of the financial impact of package management because a precise quantitative description could not always be given. She, and the National Health Care Institute itself, observed that the primary goal of the positions was not to control health care expenditure. The minister and the Institute did not comment specifically on the feasibility of the financial targets set in the Sensible Care programme.
Court of Audit’s afterword
We point out in our afterword that the minister expects package management to make a substantial contribution to savings in the future. We see this as another reason for the minister to explain clearly in the budget and the annual report both the policy-related lessons learned and the financial results of package management. This information should consider not only package management but also the positions taken. We agree with the minister and the National Health Care Institute that the primary goal of the positions is not to control the development of health care expenditure. Yet they can improve control of expenditure. The National Health Care Institute has started to map out the financial consequences of the positions and will do so more systematically in the future. In this light, we recommend that the minster and the institute clarify how they will incorporate the financial consequences into the Care Financial Picture.
In view of the financial savings that strict package management is expected to deliver as from 2017 (€225 million per annum), the Minister of VWS should clearly explain in the budgets and annual reports whether the intended savings have been achieved. Given the promising opportunities provided by the Sensible Care programme for more effective package management in the longer term, the programme should be thoroughly evaluated. The minister and the National Health Care Institute could then improve the development of package management.