Co-payments and deductibles

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1 Co-payments and deductibles Country: Netherlands Partner Institute: Institute of Health Policy & Management, Erasmus University Rotterdam Survey no: (3)2004 Author(s): Jan-Kees Helderman / Anniek Peelen Health Policy Issues: Funding / Pooling, Access Current Process Stages Idea Pilot Policy Paper Legislation Implementation Evaluation Change 1. Abstract The policy proposal described in this report aims at containing the costs of public expenditures on health care by introducing deductibles in social health insurance and the AWBZ scheme. These deductibles especially affect the 65% of the population that is covered by the social health insurance, patients with low income and high risks or chronic diseases will be affected most severe. 2. Purpose of health policy or idea The policy proposal described in this report aims at containing the costs of public expenditures on health care by introducing deductibles in social health insurance and the AWBZ scheme. These deductibles especially affect the 65% of the population that is covered by the social health insurance, patients with low income and high risks or chronic diseases will be affected most severe. In the Netherlands, health care finance is marked by a mixed system of social and private health insurance, both providing comprehensive coverage to different sections of the population. The basic premium in the social insurance sickness funds consists of two parts: (1) a uniform income-related contribution - standardized across funds - paid from payroll, and (2) a community-rated premium - that may vary across funds - paid by the insured directly to the sickness fund. In addition, sickness funds sell supplementary insurance and for this they are completely free to determine coverage as well as premiums (although all sickness funds voluntarily charge community-rated premiums). For curative care (e.g. hospital care, GP and medical specialist services, prescription drugs etc.) about 65 percent of the population (people with earnings below a legally specified income level) are compulsorily insured by sickness funds. Coverage is fully standardized and benefits are provided in kind. Provincial and municipal civil servants, accounting for about 5 percent of the population, are covered by specific mandatory health insurance schemes (also see survey number 01/2003: Integrated care/ care for the elderly). The rest of the population relies on voluntary private insurance, and about 2 percent are uninsured. Private health insurance premiums are risk-rated and depend on the chosen degree of insurance cover. Private health insurers are obliged by the Health Insurance Access Act (WTZ) to offer a standardized policy at a legally determined premium to the elderly and other high-risk groups. Any losses that private health insurers incur on these regulated policies are compensated from a pool that is filled by mandatory cross-subsidies paid by all those privately insured

2 A compulsory national health insurance scheme (AWBZ) covers long-term and mental health care. The benefits offered by the AWBZ comprise 45% of the total expenditures on health care. The scheme is financed by general taxation (10%), income-related contributions (80%), and income-related co-payments up to a certain income level (10%). The AWBZ is administered by regional care offices, which are mandated by sickness funds and private health insurance companies. Since they are fully retrospectively reimbursed for all medical expenses covered by the AWBZ, they bear no financial risk. Type of incentives Financial incentives 3. Characteristics of this policy Degree of Innovation traditional innovative Degree of Controversy consensual highly controversial Structural or Systemic Impact marginal fundamental Public Visibility very low very high Transferability strongly system-dependent system-neutral 4. Political and economic background See for the political and economical background policy survey number 01/2003: "Attempts to introduce a national health insurance scheme with managed or regulated competition among insurers and providers ( )", reported by Erasmus University Rotterdam, Institute of Health Policy & Management the Netherlands. During the period after the second purple government ( ), cost containment more or less disappeared from the political agenda. The result was an expansive growth of health care expenditures. The succeeding centre-right three-party coalition, including the new populist LPF Party, even proposed increasing the pace of liberalizing supply and price controls in order to provide incentives to reduce waiting lists. Due to an internal power struggle within the unstable LPF Party, the new government fell within three months of coming to office. The new - current - centre-right coalition has put cost-containment back on the political agenda. The new Liberal Minister of Health, Mr. Hoogervorst, came to office under tough budget constraints set by the Ministry of Finance in order to combat an economic recession. Cost-containment was back on the political agenda. A specific problem in social health insurance and the AWBZ scheme is the excessive demand for services. Since coverage is fully standardized and benefits are provided in kind and since the costs of care for any individual are spread across the pool of insured individuals and prices are distorted, individuals will have a strong tendency to overconsume health care, leading to excessively rising spending levels on health care. This is known as "moral hazard". Minister Hoogervorst now aims to tackle these problems of moral hazard by introducing deductibles in the social health insurance and the AWBZ scheme

3 5. Purpose and process analysis Idea Pilot Policy Paper Legislation Implementation Evaluation Change Origins of health policy idea Ideas were generated by the centre-right government of prime minister Balkenende. Main objective of the idea is cost-containment. Besides cost-containment at the macro level, deductibles are expected to contribute to the cost-awareness of consumers of health care, creating an incentive for more efficient use of health care. Introducing deductibles in social health insurance will also be part of the convergence of social and private health insurance into one national health insurance; the basic package of necessary care. To be implemented in 2006 (survey number 01/2003). In 2005 a compulsory deductible of 250 euro a year per person has to be realised. Patients are allowed to choose for a higher voluntary deductible in exchange for a reduction on the insurance premium. Stakeholder positions Patients will have to pay a certain amount of the health care costs. It is expected that low risk patients are willing to accept the extra voluntary deductible in exchange for premium reduction. Health insurers are positive about these idea, hoping that patients will use health care more restrictive and that deductibles in social health insurance will contribute to a sustainable health care system. The government is positive about the idea of a deductible in health care. GPs are sceptical about introducing deductibles in primary care, expecting that the introduction of deductibles in primary care will result in an expansion of more expensive secondary care. The ruling Christian democratic party struggles with the introduction of deductibles in primary care, social democrats and other left-wing parties are opposed. Liberals and social liberals are positive. There are only few policy papers about this subject yet available. There will be more next year. Influences in policy making and legislation Necessary changes in both the ZFW (Social Health Insurance Act) and the AWBZ need to be in conformity with European legislation and are subject to the judgement of the European Court of Justice in Luxembourg

4 Legislative outcome Adoption and implementation The CVZ (Board for Health Insurances) is moderately positive about this reform. The CVZ warns however for increasing administration costs of the social health insurance scheme. Monitoring and evaluation Indicators used for a sufficient implementation of deductibles are to be the results of the key monitor, which is yearly produced by the CVZ (Health Insurance Board). The key monitor contains results about the co-payment rules in home care. Evaluations results are not available. 6. Expected outcome Implementation of deductibles in health care is scheduled for Legislation has to be adapted. Especially the social health insurance act and the AWBZ have to be adapted. Problems may appear from the ongoing process of European integration. European legislation must be the guide in formulating the new system in which a deductible is built in. Quality of Health Care Services marginal fundamental Level of Equity system less equitable system more equitable Cost Efficiency very low very high 7. References Sources of Information Magazines: Zorgvisie & ZM-Magazine (all in Dutch) Policy papers of the House of representatives of the States General (all in Dutch) - 4 -

5 Reform formerly reported in Integrated Care for Elderly Author/s and/or contributors to this survey Jan-Kees Helderman / Anniek Peelen Suggested citation for this online article Jan-Kees Helderman / Anniek Peelen. "Co-payments and deductibles". Health Policy Monitor, April Available at -

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