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Public reporting and accountability. The Dutch case Gert Westert Professor of Health Services Research, Radboud University Nijmegen Medical Centre; Head DHCPR, National Institute of Public Health (2006 – 2011). Dutch health care : brief history.

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Public reporting and accountability

Public reporting and accountability

The Dutch case

Gert Westert

Professor of Health Services Research, Radboud University Nijmegen Medical Centre;

Head DHCPR, National Institute of Public Health(2006 – 2011)

Dutch health care brief history

Dutch health care: brief history

  • Untill 1940: no government regulation with respect to health insurance: private initiatives

  • 1941: mandatory public health insurance for low- and middle income groups

  • 1970-1985: Pressure on central goal: universal access, government plays important role

  • 1980s focus on control of costs

  • 2000: awareness of side effects of supply-side regulation, focus on quality. New paradigm:

    • From supply-oriented to demand-oriented (patient-centered care)

    • More important role for health insurers

    • More room for providers

    • Efficiency through managed competition

Context regulated competition

Context: regulated competition

  • Dekker – report (CEO Philips); 1984

  • “The Dutch government believes the performance potential of the health care system can be substantialle boosted if centralised state control makes room for a decentralised system of regulated competition” (Ministry of Health, 2004)

  • 2006 New Health Insurance Act

More market elements

“More market elements”

  • Consumers (18+) have to take out private insurance and receive a government defined health insurance package (broadanddeep)

  • Insurers are obliged to accept all applicants

  • Health insurers compete, and critically purchase services from providers

  • Providers will provide “more for less”, in terms of access, quality, costs

  • Government takes backseat;

    • Less “controlitis” and central planning, increasingcompetition

    • Speed up technicalandorganizationalinnovations

    • Increase responsiveness

Regulated competition

Regulated competition

  • Dutch Health Care Authority (Nza) controls the right functioning of the three markets

  • Health Care Inspectorate (IGZ) sets quality and safety standards

  • Health Care Insurance Board (CVZ) advises on the cost-effectiveness of the insurance package (toobroad, toodeep?)

  • MoH responsible for access, quality, costs, but operates at distance

  • Website to support citizens (Kies Beter/ ChooseBetter)

  • Indenpendentresearchers monitor (un)intendedeffectsand change: DHCPR

Public reporting performance assessment

Public Reporting Performance assessment

  • Public Health Status and Forecasts report

    • State of Public Health

    • Since 1993, fifth edition 2010, next 2014

  • Health Care Performance report

    • State of Health Care

    • Since 2006, third edition 2010 (May), next 2014



  • CommisionedbyMoH; independence?

  • Target group: Dutch citizens, representedby members of Parliament

  • Describe access, qualityandcosts of healthcare system (prevention – cure and long term care)

  • Uselimitednumber of macro indicators (150)

    • Time series comparisons

    • International comparisons

    • Regionalvariations/ benchmarking

    • Patiënt perspective

    • Focus on outcomes

  • Pay attention to: efficiency, effect of reforms

From assessment to action

From assessment to action

Dhcpr used

DHCPR: used?

  • Bridging the gap betweenscienceand policy is …”itisn’t love at first sight”

  • MoHprefers more thanonesource (partner)

  • SendtoParliamentbyMoH

  • Useall sources availableandsummarize

  • Providekeymessagesandan executive summary

  • Provide a research agenda (Chapter 6: Towards the next …

  • Stick toyourrole: evidenceandscience

  • Keep in mind: healthcare is aboutvalueforpatients

Issues to discuss

Issues todiscuss

  • What makes this urgent in the Australian context? Accountability issues.

  • What needs to happen in Australia to get PR established? Barriers and enablers.

  • Role of Independence and engagement all stakeholders.



Does it work the dutch model

Does it work, the Dutch model?

Most important issues 2013:

  • Access is good, qualityvaries

  • Insurers tend to contract on (total) price and less on quality, but licensetooperate is at stake …

  • System is focussed on volume of healthcare; shift towards value for patients needed

  • Expenditure growth not sustainable … 14% GDP

  • Transparancyandquality information: opaque, but improving, focus on outcomes

Healthcare reforms 2006

Expenditure growth notsustainable

14% GDP

Healthcare reforms 2006

Health expenditures percentage GDP

Does this work in a period of economic downturn

Does this work (in a period of economic downturn)?

Public reporting and accountability

Dutch GP’s: 59 percent state thatpatientsreceivetoomuch care

IHP 2012, Commonwealth Fund

For a few dollars more well spent

“For a few dollars more”: well spent?

  • Waiting lists (2001): ∨

  • Hospital productivity: ∧

  • Life expectancy ∧

Pay for volume

Elderly use more services, lower mortality

Is this too much or value for money

Is thistoomuch or valuefor money?

  • No waiting lists: overtreatment?

  • Expenditures up: price and volume issues (cataract surgery)

  • Practice variation huge, but invisible (IQ healthcare, 2012)

  • GPs and hospital physicians: “live in separate worlds”

    • Separate budgets and income schemes induce overdiagnosis and - treatment

    • GP per enrolee/ service (60/40);

    • Hospital (physician) paid fee for service/ volume

What s next

What’s next

  • Government: expenditure / hospital volume growth restricted (2.5%)

  • Out-of-pocket 50 EURO for visit ER (bypassing the GP)

  • 350 EURO deductible for hospital care

  • Tracking unnecessary or unwarranted care (20 – 35%)

  • TRANSPARANCY: how much we spend; what we spend our money on (activities) and what the outcome for patients is, but … disruptive

  • Nobody really wants to know: payer, provider, politicians caught in a trap >>> patients can help

Geographic perspective


Utilisation (VOLUME)?


Outcomes (VALUE)?

Public reporting and accountability

Back hernia,




Varicose veins




Dutch Atlas of Health Care Variation:

Elective surgery

1. Huge variation in activities (pilot)

2. What is the price of activities at local level?

3. What is the value for patients?

We don’t know? Need to measure outcomes

Public reporting and accountability

Public reporting and accountability

The Federation of Patientsand Consumer Organisations in the Netherlands (NPCF).

Public reporting and accountability

We have a problem

“We have a problem”

  • Neurosurgeonpresentedtocolleagues (Wilco Peul): back hernia surgery

  • Factor 3 to 4 betweencatchmentareas

Response brothers in arms

Response “brothers in arms”

  • Data isn’t right

  • Data maybe right, notmyproblem

  • My patients are different

  • Let’s take a look



“50% van de zorg die wij bieden is onzin, we weten alleen niet welke 50%” (oncologe)

Public reporting and accountability


  • Medical uncertainty is huge

  • 50% is effective

  • We see more, but far less important things

  • Professional autonomy (in isolation)

  • Cookbook medicine

  • Art and improvisation versus scientific approach

What is definitely wrong

What is definitely wrong

  • We payfor “income”, notforoutcome

  • Quantitydominatesquality

  • Doingdominates“watchfull waiting”

  • More is better >>> Less is more

Public reporting and accountability


Public reporting and accountability


Categorize care in 3 categories

  • Effective care: 25%

  • Preference-sensitive care: 25%

  • Supply-sensitive care: 50%

Public reporting and accountability


  • Signalpracticevariation on map (utilisation, costs, outcomes)

  • Use these signalsto get stakeholders in a room (lock the door)

Public reporting and accountability


  • Shared decision making: the silent misdiagnosis

  • T = f(Md, Pd)

  • Doctor and doctor



  • Most of the time we do thingsgood, but are we doing the right thing?

Further reading

Further reading



Public reporting and accountability


Gert Westert

Let’scollaborate; we need

more fingersforourdykes!


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