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1 To: James Woollard, Geraldine Strathdee From: Chris Nas, Eddy Faber Date: September 25th, 2014 Subject: Mental health policies and waiting times in the Netherlands Background In the UK, choice between mental health care providers became a legal right in April However, this system is not operationally working yet and at the moment no standards in waiting times have been developed. The NHS wishes to introduce waiting times in a useful way by April 2015, alongside other policies and systems. The question asked is how the Netherlands addressed the issue of waiting times in mental health care, with specific attention for these five questions: 1. What policy measures did the government take? 2. The cost of implementing waiting times - did mental health services need extra money to meet waiting times and if so how was this allocated? 3. Was there a significant change in the use of mental health services because of the changes the government introduced - did more people access services? 4. Were outcomes seen to improve for people with introduction of waiting times? 5. What was the experience of the Netherlands in collecting and collating data to monitor waiting times? For answering these questions, we used three main sources to get information: OECD working paper on the Dutch mental health system of 2014 (Forti et al ) RIVM paper on the cost development in Dutch mental health (Folkertsma et al ). Several publications and data of GGZ Nederland on waiting lists and number of patients. Headlines In the past 12 years, Dutch government initiated several policies to guarantee accessible and affordable mental health services of good quality. Reducing waiting times was an important goal of these three policies in 2000: increase funding, introduction of primary mental health care and reduction of stigma (paragraph 1). At first sight, waiting times did not decrease significantly in the past years (paragraph 2), despite a much higher budget for mental health services (paragraph 3). However, this investment did lead to more supply of services and a significantly higher demand: more people were able to use mental health services within a reasonable time and unmet need is very low (paragraph 4). It is not calculated how long waiting times would have been without a higher budget. GGZ Nederland (annex 5) has monitored waiting lists in mental health care for 6 years. The experiences in the first few years led to a new way of reporting waiting times: the realized waiting times of people whose treatments actually had started (annex 2). 1 Forti, A., et al. (2014), "Mental Health Analysis Profiles (MhAPs): Netherlands", OECD Health Working Papers, No. 73, OECD Publishing. 2 Folkertsma, J., A. Marijke, J. Polder, G. J. Kommer, L. Slobbe, M. van Tulder (2013), Effects of Policy Measures on Mental Health Care Expenditures in the Netherlands, Ministry of Health, Welfare and Sport. 1

2 1. Overview mental health policies In 2013, Folkertsma et al (2013) published an overview of mental health and the impact on accessible, affordable mental health care of good quality (see page 3). In an effort to improve the functioning mental health system, the Dutch government introduced a number of policies and the sector of course responded. Modernization of the Exceptional Medical Expenses Act (AWBZ) In 2002, the policy on eliminating waiting lists was introduced. Health insurers were able to put more care under contract; therefore, care suppliers could produce more care. This policy was part of the modernization of the AWBZ. Extra production of care was needed to comply with the growing mental health care demand and to eliminate the continuously growing waiting lists. The government released the budget maximization in 2002 and the expenditures rose with 240 million (7.5%). The waiting times increased with 22%, the waiting lists decreased with 7% due to more care supply. Because of this growth of expenditures, and the marginal decrease of waiting lists, the budget maximization was reintroduced in At the same time, the number of people with access to treatment increased significantly, the unmet need decreased significantly. Introduction and implementation of Diagnosis Treatment Combination (DBC) In 2008, the Diagnosis Treatment Combinations (DBC s) were introduced and gradually implemented. Nonbudgeted care providers established themselves in the (primary) care market, which resulted in a large growth (262%) of new and non-budgeted care providers in The number of budgeted care providers has been stable. Budgetary care providers did have a safety net option so the organisations could grow into a new situation. This safety net was discarded in One goal of DBC s is more transparency of mental health care, but the health insurers found the transparency insufficient. It is assumed that DBC s provided more insight in the costs and use and thus led to more transparency. However, a sharp increase of the administrative burden and necessary ICT investments resulted in a one-off cost rise of 1.4 billion. As the effect of DBC s on transparency in quality was limited, the sector started a nation wide project in 2009 to introduce Outcome Monitoring in Mental Health with the aim to open the black box of mental health care (Forti et al, 2014). It is not possible to use these data to evaluate the outcomes of these governments policies. Transfer of the curative care from the AWBZ to the Health Insurance Act (Zvw) Also in 2008, curative mental health care was transferred from AWBZ to Zvw. The curative mental health care contains all outpatient curative care and the first year of inpatient curative care, even lengthy residence. Since 2008, the Zvw is financial responsible for the curative mental health care. The AWBZ care takes care of all noncurative in- and outpatient mental health care, as well as the second year of treatment and further inpatient care (CVZ 2008). The AWBZ is responsible for 30% of total mental health care expenditures, while 4-6% of all patients receive AWBZ financed care. With the transfer, parity of esteem between physical and mental health care has been achieved. However, this change did lead to increasing waiting times. The flexibility between the two finance systems no longer existed and the budget could not be transferred from the AWBZ to the Zvw. Further, health insurers are confronted with waiting lists in the AWBZ. The shift of patients from primary to secondary mental health care was therefore impeded and did lead to higher costs and a lower quality of care. The costs of the transfer were calculated to be up to 1.1 billion Euros: 500 million more spending on mental health care, the other 500 million a one-off administrative expenditure. 2

3 Modernization of the Exceptional Medical Expenses Act (AWBZ) Introduction/ implementation of Diagnosis Treatment Combination (DBC) Transfer curative MHC from AWBZ to Health Insurance Act (Zvw) Introduction Care Intensity Package (ZZP S) in secondary MHC Introduction co-payment in secondary MHC Goals Elimination of waiting lists Cost control through efficiency, transparency, quality and better responsiveness Input Instruments Through-put Process Output The extent to which the goals are achieved Outcome Overall goals of health care Releasing budget maximization Due to an inadequate waiting list registration, there was insufficient information about the waiting lists. However, an increase of 6% new patients, next to 7% increase of production can be seen. The number of waiting patients decreased with 7%, the mean waiting time increased with 22%. Quality + It is expected that expanded treatments, more supply and shorter waiting lists will increase the quality of care. Accessibility - Increase of the waiting time with 22%, but decrease of the waiting lists with 7%, due to more care supply. Affordability -- MHC expenditure rose with 240 million. More supply leads to more demand. Abolition of the budget systematic, introduction of a new finance system The introduction took place at the same time as the transfer of the curative MHC. This had financial impact on the care suppliers due to the late start up of DBC declaration for the non-budgeted MHC suppliers and the disbursement for the secondary MHC. One-off cost rise of 1.4 billion. DBC s led to perverse incentives in MHC care and demand. For care suppliers the DBC s led to more transparency, for health insurers the DBC s are insufficient transparent. Quality More insight in costs and use of care, although effect of DBC s on quality of care is unknown. Accessibility + Establishment of many new care suppliers what leads to better accessibility of care. Affordability -- No budget maximization, the turnover could be much higher than budgeted, which led to a large increase in expenditure. Efficiency profit, more consistency in care, cost control Transfer of all curative MHC from AWBZ to Zvw. Release of extra budget for the Zvw. This transfer took place at the same time as the introduction of the DBC s. Both policy measures had major impact on MHC. Secondary MHC has waiting lists, a small part of primary MHC also. The transfer from primary to secondary care is impeded by waiting lists. No flexibility between the two systems lead to waiting lists for secondary and primary MHC. The transfer led to a large growth in MHC expenditure. Because of longer treatment duration, consistency in care is disadvantageous for the MHC. Quality - No flexibility between the two finance systems, this seems to have a negative effect on the quality of care. Accessibility The referral is more difficult and therefore waiting lists arise. Affordability -- Because there is no transfer possible between the two systems, an increase of MHC expenditure can be seen. Focus on the patient, better distribution of costs and more insight in care intensity Budget is related to the actual production of care institutions The transition to care based on personal needs of the patients caused much effort of provider and patient. Care agencies, and in the future, health insurers, have an important role to support the care suppliers to provide higher quality of care. More insight in care intensity, focusing on the patient. However, financing per patient appears to be too expensive, a discount is applied to hatch budget neutral. Quality + More insight in care, but the effect of ZZP s on the quality of care is unknown. Accessibility With a right indication, the ZZP s had no positive or adverse effect on the accessibility. Affordability Actual costs of ZZP s are higher than current budget, the government adjusted for this. For the care supplier this is detrimental when in ZZP s arranged care is supplied. Fostering primary MHC referral, cost control in secondary MHC. Co-payments in the secondary MHC (except for youth, forced care and crisis care) To ensure access of MHC, the co-payment is before introduction decreased from 275 to 100 per DBC. For 2013, alternative measures will be studied. The final effects of the copayment are unknown by now. Expected is that, in the short term, the policy measure is highly effective to reduce the demand of MHC. Quality There is a risk that financial, instead of medica considerations, determine the care supply and care demand. Accessibility Health differences between poor and rich may grow. In other countries this phenomenon is hardly observed. Affordability + Co-payment leads to more awareness in use of care. However, substitution to other sectors should be avoided 3

4 Introduction Care Intensity Packages (ZZP S) in the secondary mental health care In 2010, Care Intensity Packages (Zorg Zwaarte Pakketten, ZZP s) in secondary mental health care were introduced. A ZZP is a description of care intensity and is based on patient s personal needs. The budget of health suppliers depends on the care intensity of patients. The ZZP s gain more insight in patient s care intensity and lead to a central role for the patient in the mental health organisations. In addition, the costs are better distributed since the budget is based on patient s needs. Main drawbacks from the ZZP s for mental health care organisation are the required complex indication of patients, this leads in particular to a higher administrative burden. Introduction of co-payment in the secondary mental health care The introduction of co-payments in the secondary mental health care took place in Copayment was already introduced in the primary mental health care in 2009, which has led to substitution of primary mental health care by more expensive secondary mental health care. The copayment was introduced to stimulate more conscious use of care and better cost control; it was already abolished in Waiting times in Dutch specialist mental health care In January and April 2000, representatives of (para)medical professionals, health service providers and health insurers met at the Treek (a forest area in the Netherlands). At these meetings, they agreed upon standardised objectives for waiting times in non-acute healthcare. These so called Treek Objectives should been effected on 1 January Table 2: Overview objectives and maximum waiting times for non-acute mental health care Cure outpatient Cure inpatient Sheltered housing Admission 3 weeks 80% 4 weeks maximum Diagnostics 3 weeks 80% 4 weeks max. Treatment / support 4 weeks 80% 6 weeks max. Source: Treek Conference, January 2000 and April weeks 80% 4 weeks max. 3 weeks 80% 4 weeks max. 5 weeks 80% 7 weeks max. 1 week max. 3 weeks 80% 6 weeks max. 8 weeks 80% 13 weeks max. The Treek Objectives used these definitions for waiting times: Admission/appointment: Time in calendar days, measured at one set date every month, between the day on which a new patient makes the first appointment at a specialist and the day of the first session. In longterm care, the time in calendar days between the registration for assessment and the day of assessment. 3 Source: 4

5 Assessment/diagnostics: Treatment/support: Time in calendar days, measured at one set date every month, between the day on which an appointment for is made for diagnostics/assessment and the day that diagnostics/assessments are completed, including the result. Time in calendar days, measured at one set date every month, between the moment of registration in the waiting time information system of the service provider and the day of first treatment. Around 2004, GGZ Nederland extensively analysed the waiting lists and waiting times in mental health care. This provided valuable insights and assisted with the development of a methodology to measure waiting times in a meaningful way. In short, these are the most important guidelines: 1. Determine standardised objectives (in this case the aforementioned the Treek Objectives). 2. Focus on waiting times, instead of the number of people waiting 3. Determine the realised waiting times (instead of waiting times at a set date). 4. A consequence of point 3, only calculate waiting times of people no longer waiting (e.g. because treatment has started). Table 3 shows the waiting times in mental health care between 2002 and 2009 per calendar year for 3 age groups and for each waiting stage. The numbers are the average waiting times in weeks of all clients in that specific calendar year. Between brackets and in italic, the percentage of clients that had to wait longer than the Treek Objectives for mental health. Table 3: overview waiting times mental health care between 2002 and 2009 Children / youth (0-17) Waiting stage admission assessment treatment (51) 7 (41) 4 (19) (51) 7 (42) 5 (24) (48) 7 (46) 6 (30) (47) 8 (50) 6 (29) (52) 6 (43) 5 (27) (50) 6 (37) 6 (27) (51) 7 (44) 7 (32) (49) 6 (40) 6 (28) Adults (18-64) Waiting stage admission assessment treatment (29) 4 (24) 3 (16) (27) 4 (26) 4 (18) (23) 4 (28) 4 (20) (19) 4 (29) 4 (19) (22) 3 (26) 4 (18) (25) 4 (29) 5 (23) (25) 4 (31) 5 (24) (25) 4 (32) 5 (23) 5

6 Elderly (65-) Waiting stage admission assessment treatment (21) 2 (15) 3 (13) (21) 2 (16) 3 (17) (14) 3 (22) 3 (14) (14) 3 (26) 3 (13) (14) 3 (21) 3 (14) (15) 3 (24) 5 (21) (17) 3 (27) 5 (22) (16) 3 (27) 5 (21) Source: Compilation of various waiting times reports produced by GGZ Nederland between As of 2010, there is no longer a national registration for waiting times in Dutch mental health care. Mental Health service providers are still required by law to publish the waiting times for different services and locations on their website. 3. Budget mental health care The Gross Healthcare Budgetary Framework (Budgettair Kader Zorg, BKZ) has almost doubled from 2000 to 2010, from EUR 2.78 billion to EUR 5.09 billion, almost at exactly the same rate as costs for health care in general during this period (figure 1). Figure 1: Expenditure mental health care according to Health Care Budget Framework. Source: Folkertsma et al, 2013 Mental health care costs did decrease in 2012, contrary to the current general trend in health care, where costs are continuing to rise (Forti et al, 2014). Data also show that the increase in mental health care expenditure was not driven by an increase in prices, but rather by an increase in volumes (figure 2). 6

7 Figure 2: Increasing volume dominates increasing prices Source: Folkertsma et al, Use of Dutch mental health care mental health care Although the mental health of the Dutch population did not change much over the past decennium, the demand for mental health care increased in this period due to social changes (figure 3). Figure 3: absolute production of mental health care organisations Source: Van Dijk, Knispel et al. 2011, Trimbos Institute. *No figures available of part-time therapy in First, the government played a major role in reducing stigma, hence increasing accessibility to mental health services. This policy led to a better-organised mental health care, faster identification of mental problems in the primary care, and more attention for prevention. This resulted in a higher demand of mental health care and sharp decline in unmet health care needs (Folkertma 2013). 7

8 Figure 4: Self-reported utilisation of medication and any form of health care because of psychiatric problems, alcohol or drug problems (in the 12 months preceding the survey) by the Dutch population between years old Medication (%) Any form of mental health care (%) Unmet need (%) Mood disorder Anxiety disorder Substance abuse ADHD Any Axis-1 disorder No axis-1 disorder Total population Source: de Graaf, R., M. ten Have and S. van Dorsselaer (2010), De psychische gezondheid van de Nederlandse bevolking. Nemesis-2: Opzet en eerste resultaten. [The mental health of the Dutch population. Nemsis-2: design and preliminary results]. Utrecht: Trimbos Instituut. [in Dutch] However, the number of unique patients in 2012 has dropped from 827,300 in 2009 to 777,900 in 2012 (figure 5). This is also the case for the number of treatments (from 884,500 to 818,900). This drop is sharper in 2012; this may coincide with the introduction of specific co-payments for mental health care in Predictions are that the patient s income will determine the demand of mental health care, which means that in particular patients with a low educational level and a low income will stop or reduce their use of mental health care. However, the co-payments were abolished after only one year. It is not clear yet what the effect of this policy in 2013 will be. Figure 5: Number of unique patients and treatments in specialist mental health care number of patients number of treatments ** Source: GGZ Nederland (2014), Sectorrapport 2012: feiten en cijfers over een sector in beweging [Mental health industry report 2012, facts and figures on an industry in transition]. ** estimation based on period of November 2011 to October

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