Managing costs and access to healthcare in the Netherlands: impact on primary care

Financing changes

Not-for-profit sickness funds, which until 2006 had covered about two thirds of the Dutch population, reformed into for-profit organisations or merged with private health insurers. All citizens were required to purchase a basic package of essential healthcare services that was set by the department of health, along with cover for “own risk” (the amount of their total annual claims that policy holders have to pay themselves). The premium for the basic package is set annually by insurers in competition with one another; they have to accept everyone who applies, without exception. People on low incomes receive a subsidy for the basic insurance.12 The primary care structure introduced in 19414 was largely maintained in the reform: patients continued to be registered with a general practitioner (GP) and were able to access specialised healthcare only through that practice. GPs thus continue to be responsible for access to care and for most health problems.125 The general practice funding model changed from a full capitation fee for patients registered into a partial fee-for-service payment, although capitation payments remained practices’ main source of income.

The 2006 reform did not immediately bring about cost containment (fig 1), although annual increases in costs did begin to fall after subsequent measures were brought in.67 The changes also gave rise to concerns about the health of people on lower incomes, those with mental and chronic health problems, and other vulnerable groups.89

Fig 1

Percentage annual increase in Dutch healthcare expenditure6

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Further organisational and financing measures were introduced in 2007, 2008, and 2015 (table 1).3 These were directed at the roles of insurers and municipalities in containing costs and improving the quality, coordination, and integration of care. The measures covered a broad range of health issues, aiming to financially support patients with chronic health problems89 and to expand the role of primary care and other community services. Two measures in particular increased the workload for GPs.

New roles for primary care

Mental healthcare was reformed in 2014. GPs were given a central role as providers, with the option to refer patients to basic mental healthcare services providing short term interventions by psychologists or psychotherapists if required. This reform proved to be cost effective: costs fell by around €2000 per patient compared with the old system.10 Specialised care is available for patients requiring long term care and those with high risk disorders. GPs were able to negotiate extra funds from insurers to enable them to employ more mental health practice nurses. This created additional capacity to respond to increased demands.

Hospital funding for emergency care was changed so that instead of being reimbursed for all costs incurred—including referrals to other secondary care facilities—they received a standardised “emergency care fee.” Hospitals started working with GPs through out-of-hours collaboratives and hospital emergency departments. As a result, a much higher proportion of patients attended their on-call GP, and self-referrals and hospital admissions fell.1112 Fully integrated out-of-hours care (urgent care collaboration), with GPs acting as gatekeepers to hospital emergency departments, led to a 20-50% reduction in the number of patients using hospital emergency care compared with the usual care setting.1213

GPs and other primary care providers were able to deliver the extra services because of the strength of the health system since 1941. Dutch healthcare has a long history of a central role for GPs as gatekeepers to access to specialist care for their patients and a thriving academic tradition of education, research, quality assurance, and professional development.1415161718 The success of shifting emergency out-of-hours care payments to a standardised fee shows that it is possible to disincentivise patients from accessing secondary care directly.

Providing services at the community level for mental health and chronic care, improved quality and equity. To ensure the psychosocial health of young people the collaboration of primary care with other community based services—for example, schools and education programmes or family support—was strengthened; this is another key feature of primary care.19

Healthcare costs and population health

Figure 1 shows annual increases in healthcare expenditure from 1999 to 2017.67 The percentage increase fell after 2008, with the increases smaller than the growth in gross domestic product (GDP) during this period.67 A similar pattern is seen in the UK.20 This trend corresponds to budget cuts in the system before 2004, when the health reform law was presented to parliament. Preparatory and transitional investments had already been made to implement the law as soon as possible. From 2008 onwards, the new system was in place, leading to better control of expenditure. The increases in the past few years are probably a result of the underlying trends of an ageing population and advancing technology—a challenge to all Western societies, independent of their healthcare or political systems.2122

Although no conclusions on causes and consequences can be drawn from our analysis, we hypothesise that the expanded role of primary care contributed to the containment of costs. The number of people with a chronic health problem continued to rise, but the numbers with limited activity remained stable.523 Furthermore, the population’s satisfaction with healthcare remained high and above the average for countries in the Organisation for Economic Cooperation and Development.24

Strengths and weaknesses

The 2006 healthcare reform in the Netherlands combined all costs in primary and secondary care into a single comprehensive budget, enabling cost assessment over the full range of services provided. The reform created opportunities for (local) care arrangements and initiatives. In this way, an innovative health system is able to respond to local communities’ needs through arrangements with other services, such as community welfare services or sport club facilities.

Care was redirected towards primary care services, but without targeted investment in that sector.25 The workload of GPs and its complexity increased substantially, resulting in increased work pressure and risk of burnout.26 Part of the problem was that hospital care that was redirected to primary care was often brought under the capitation payment for GPs, and as a consequence additional demand for GPs’ services was not matched with additional financial support. No indicators exist for measuring primary care performance specifically (continuity, person centredness, holistic care)27 to guide investment through pay-for-performance. Any further expansion of the role of primary care will need to be accompanied by further innovation and investment in the sector, to secure its sustainability.

Health insurers inevitably have a short term interest in securing their business models in a competitive context. This is at odds with their supposed role of securing the long term health interests of the population—which may explain their reluctance to invest in preventive interventions and healthier lifestyles.23 Investment in prevention would result in policy holders having better health status and thus lower health costs later. But these lower health costs might benefit a competitor if the policy holder had changed insurer by that time. Better integration of individual primary care and population based public health may resolve the division between preventive and curative services and secure a more balanced allocation of funds.28

Lessons for other countries

The experience of the Dutch healthcare system over the past decade provides numerous lessons that may apply to other countries. The complexity of healthcare with an ageing population means that no single policy measure is going to be sufficient to change the system’s performance. Introducing new organisational principles—such as market mechanisms with competition between providers—is one challenge, but making such principles work in practice is quite another. Ongoing governance and pragmatism are required for this.

The 2006 reform could be regarded as an experiment in a competitive healthcare market, and developments over the past decade cast doubt on its effectiveness. For-profit healthcare funders will find themselves in a conflict between their short term interest of increasing profits and their long term interest of improving the health of the population. In most countries, (universal) health coverage focuses on curative services at the expense of tackling risk factors and harmful behaviours—such as insufficient physical activity, smoking, and alcohol use—which disproportionately disadvantage less wealthy populations.2930

The example of emergency out-of-hours care shows that it is possible to disincentivise patients from accessing expensive secondary care directly. But what may be of interest for other countries is the context of a well established primary care system in the Netherlands, as it underlines the importance of investing in primary healthcare—a message that remains relevant for Dutch health policy makers too. All healthcare systems need ongoing investment in the capacity of general practice and primary care to enable them to work with other community providers to promote health through lifestyle medicine30 and to prevent and, where necessary, treat disease. Such investment is crucial to accommodating the changing health needs of populations and containing rising healthcare costs.