Top down or bottom up?
Managed Care in the Netherlands and Switzerland.
The increased need of medical care among ageing populations is causing cost explosions across Europe. Some countries tackle this challenge with Managed Care processes: Controlled interventions in the healthcare system aimed at getting doctors, patients and insurers to follow a more balanced, forward-looking path. Using different control models, the Netherlands and Switzerland have shown that it is possible to achieve significant cost savings without any loss of the quality of care.
Competition, bonuses and competent patients secure the future
‘Fewer and fewer workers must care for increasing numbers of patients. Our system is on the brink of collapse – something has to happen,’ said Professor Jo Caris of the TIAS Business School in Tilburg, the Netherlands, during the BMC Congress ‘Managed Care in Europe’.
In January 2006, the Netherlands introduced a new medical insurance law in January 2006 that moved the system away from the principle of comprehensive solidarity and closer to a system based on competition, self-regulation and choice: Every adult Dutch citizen takes out a basic insurance services package, regulated by the state, with a private medical insurer, which is independent of income and currently set at 1,050 Euros a year. In addition, contributions of 6.5%, which are dependent on income, have to be made, most of which are covered by employers and form the basis of the risk structure compensation scheme. ‘Changing the financing system in itself does not prevent the uncontrollable consumption of medical services though.
We had to emphasise to patients that medical care costs money and give them incentives to save money,’ Prof. Caris explained. Therefore, the Netherlands additionally implemented a reimbursement system whereby patients who only had basic medical care from their GPs were reimbursed contributions of up to 255 Euros. Patients can also make additional savings if they join group contracts or agree to take on part of any treatment costs, if and when they arise: ‘These simple measures have proved to be very effective. People now get more involved in saving money and develop more realistic expectations’ the professor pointed out. ‘Too much control and regimentation, on the other hand, is bad for the healthcare system.’ According to this expert, action is also needed from the doctors: Efficient treatment is based on three things: Specific medical therapy, referral to supportive social institutions and enhancing patients’ health competence. ‘We tend to start large-scale campaigns that point out to people that their lifestyles are damaging and which actively encourage them to stop smoking. But, when people are actually ill, we only involve them in their own treatment in a more passive manner. The patient is therefore put under tutelage. He feels left alone, is scared and lacks the competence to help himself when he is ill. We have to give patients more and better information about their illnesses and increase their ability to act. Competent patients can make significant contributions towards avoiding unnecessary costs.’
Prof. Caris cites as a positive example the treatment of children with attention deficit hyperactivity disorder (ADHD). Here the combination of medication, supportive family therapy and the strengthening of their own competence for those affected, by, for example, making their daily routines more structured, is having the maximum effect. ‘Better quality at lower costs: To achieve this goal, patients and healthcare professionals should be ready for the market,’ Prof. Caris concluded.
Control of medical treatment and quality assurance is down to the GP
The introduction by law of Managed Care in Switzerland occurred as far back as 1996. Other than in The Netherlands, the system is not regulated top-down, but bottom-up, with the legislator almost completely passing on the responsibility for efficient and cost-effective medical care for the population to general practitioners (GPs). This system is based on so-called medical networks – around 56% of doctors have so far decided on interdisciplinary co-operation within an integrative network. ‘Within the medical network, the GP as the gatekeeper is the central point of contact for patients. In case of illness, people are always initially seen by their GPs. The GP controls medical services and, if required, refers patients to specialists within his network. Through the co-ordinated control by one person therapy turns out efficient and cost-effective and duplicate examinations can be avoided,’ said Dr Peter Berchtold, of Forum Managed Care, Switzerland. ‘Compared with traditional care, the cost saving lies at between 10% and 35%,’ he continued. ‘Doctors who have become part of these networks show a lot of their own initiative. They are not only interested in cutting costs but also in quality assurance. There have been particular improvements in information transfer. A computer network that documents all therapeutic measures in electronic form and is accessible for everyone involved in treatment, was also set up alongside the medical networks over the last few years. Patient safety has increased significantly.’
More quality and more safety – the new system also appeals to patients, particularly as it is worthwhile financially. About 30% of all those with medical insurance decided on treatment within a particularly medical network and therefore received bonuses of up to 20%. Regular contributions can also be lowered if patients agree to take on a higher share of costs, if and when they arise. ‘The system of differentiated, additional contributions is very popular in Switzerland, he said. ‘Many patients also use the telephone advice services that have recently been introduced. These provide competent information before costs even arise.’
So far the managed care measures implemented have been mainly restricted to out-patient care and less so to inpatient services. Hospitals, rehabilitation clinics and out-patient care services should follow suit, Dr Berchtold believes. ‘Co-operation and networks are becoming increasingly important as health is always an interdisciplinary matter. Those who don’t co-operate will not survive within the healthcare market of the future’
14.11.2007
