Optimalisatie van de werkingsprocessen van het Bijzonder ... - KCE

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194 Special Solidarity Fund KCE Reports 133 Health insurers The Dutch health insurers, about 30 are active in the Netherlands, are private actors that are allowed to make profits. However, registration with the Supervisory Board for Health Insurance (CTZ) is required to qualify for payment from the risk equalization fund. Indeed, with respect to the standard benefits package, insurers are compensated by the Government for accepting high-risk patients through a solidarity mechanism (Centrale Kas / Risicovereveningsfonds – Central Fund / Risk compensation Fund). With respect to the standard benefits package (provided by the statutory health insurance), all health insurance providers (zorgverzekeraars) are bounded by acceptance obligations (aanvaardingsplicht), which means that they cannot refuse patients or patient groups as client. In exchange for the acceptance obligations, the Dutch government compensates the risks that health insurers face of having a higher number of risk patient groups in their clients base (patients with a relatively high probability of relying on sickness funds). This risk compensation system, or risicovereveningssysteem in Dutch, is applied on both ex-ante (Hogekostenverevening – HKV) and ex-post estimates (hogekostencompensatie – HKC). The definition and categorization of risk patient groups is not explicitly limited to rare diseases, but is broadly defined to all costly chronic diseases. Health insurance providers appear to identify about 3-5% of their clients as high potential risks. Hence, health insurance providers reimburse the costs for drugs and treatment to older patients or patients with rare and chronic disease. The Dutch Government compensates health insurers for the risks they are taking with accepting specific patient groups. For patients that suffer from rare diseases, the compensation by the Government to insurance providers can amount to 90% of the total costs. Healthcare providers Physicians are directly or indirectly contracted by private health insurers, based on bilateral negotiations. GPs receive a capitation payment for each patient on their practice list and a fee per consultation. Most specialists are hospital-based. Two-thirds of hospital-based specialists are self-employed and are paid on capped fee-for-service basis. The rest is salaried. Experiments with pay-for-performance are just a matter of time. Most Dutch hospitals are private non-profit organizations. Hospitals are increasingly encouraged to obtain capital via the private market. From 2000, payments to hospitals were rated according to performance a number of accessibility indicators, a measure designed to reduce waiting lists. A new system of payment for specific products, called the Diagnosis Treatment Combination (DTC), is currently being implemented. This new system introduces a system of hospital output prices that are based on the production process rather than on budgets and financing rules. The system based on Diagnosis and Treatment Combinations (DTC) is expected to solve existing problems with insufficient production incentives and a lack of efficiency within the hospital. Government With the 2004 reform of the healthcare system, the Dutch government introduced a so-called ‘regulated competition’ among health insurers, based on the idea that competition among health insurers (but also among healthcare providers) would decrease healthcare expenditure and result in a more cost-efficient healthcare provision. As the healthcare providers and insurers are operating in a system where they have to negotiate with each other on price and content of medical care, the role of the Government has evolved towards supervision and setting frameworks.
KCE Reports 133 Special Solidarity Fund 195 9.16 INTERNATIONAL COMPARISON: SPAIN 9.16.1 Sources 9.16.1.1 Publications • The Spanish health care system: lessons for newly industrialised countries, E. Rodriguez,e.o., Health Policy and planning; 14(2), 164; Oxford University Press 1999. • Durán A, Lara JL, van Waveren M (2006). Spain: Health system review, Health Systems in Transition, 2006; 8(4):1–208. • Sistema Nacional de Salud España; Ministerio de Sanidad y Consumo, 2008. • Edición limitada para la Jornada de Presentación Oficial de la Estrategia en Enfermedades Raras del Sistema Nacional de Salud, Ministerio de Sanidad y Politica Social. • Plan de atención a personas afectadas por enfermedades raras 2008-2012, Junta de Andalucia, Sevilla Consejería de Salud, 2007. • Plan de Salud de Extremadura 2005-2008, Junta de Extremadura http://62.175.249.88/syc/Inicio.pdf . • Plan Integral de Enfermedades Raras en Extremadura 2009-2014 (PIER). • Orden para la creación de una Comisión asesora en enfermedades minoritarias, Departamento de Salud de la Generalitat de Catalunya, Diari Oficial de la Generalitat de Catalunya; DOGC núm. 5379 - 14/05/2009. • Feder; Pacto de estado por las enfermedades raras. FEDER – Departamento de Comunicación, María Tomé comunicacion@enfermedades-raras.org/ www.enfermedades-raras.org. • Feder (Federación española de enfermedades raras); Consideraciones al proyecto Real decreto sobre disponibilidad de medicamentos en situaciones especiales. • Fundación FEDER, Declaración de principios: Del Pacto de Estado por las Enfermedades Raras Madrid, 25 de noviembre. • Reflexiones sobre el proyecto de real decreto para la disponibilidad de medicamentos en situaciones especiales, Lourdes Girona Brumós y Juan Carlos Juárez Giménez; Farmacia Hospitalaria, 2009;33 (3):121-2 www.elsevier.es/farmhosp. • Agencia Española de Medicamentos y Productos Sanitarios (AEMPS), Memoria de actividades 2007. • Plan de atención a personas afectadas por enfermedades raras 2008-2012, Consejería de Salud, Junta de Andalucía. • Acceso a medicamentos en situaciones especiales, Javier Bautista Paloma; VI Jornadas de ensayos clínicos Andalucia 2009, Málaga 25-26 junio. • Acuerdo del Pleno del Senado por el que se aprueba el Informe de la Ponencia de estudio encargada de analizar la especial situación de los pacientes con enfermedades raras y, especialmente, las medidas sanitarias, educativas y sociales que contribuyan a un adecuado tratamiento de los enfermos y de sus condiciones de vida, aprobado por la Comisión conjunta de la Comisión de Sanidad y Consumo y de la Comisión de Trabajo y Asuntos Sociales en su reunión del día 18 de diciembre de 2006 (543/000016 BOCG, Senado, serie I 23 de febrero 2007 Num. 659.
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