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154 Musculoskeletal & Neurological Rehabilitation KCE reports 57 Supplemental plans are available on an individual basis or collectively via an employer plan or similar group arrangement. Insurance companies will not be required to accept all applicants for supplemental insurance. Companies are free to determine the scope of coverage and premium levels for supplemental policies The “wet maatschappelijke ondersteuning” (WMO) (law societal support) will replace the AWBZ .A clear separation in the overall insurance model will be made between chronic conditions and temporary conditions. The medical and paramedical parts of the AWBZ will in the future be transferred to the ZFW. 142 143 The WMO will be mainly guaranteeing social support coordinated by the local communities. 8.3.2.1 Health care policy making and organisation 8.3.2.2 Financing The historical changes in the Dutch health care system can be characterized as a movement towards territorial decentralization, and in the last decade a movement towards integration and coordination of the different levels of the health care providers. The Dutch system holds to a model of centralized supervision, but operational responsibilities in health and social care are delegated to the local and regional authorities. The ministry of health, welfare and sport (VWS) sets out the health, health care and social care policies, together with the minister. Local authorities bear joint responsibility and play a complementary (local) role. Regional networks of municipal public health services take up the care on preventive level and health promotion (among other public health tasks). Primary care is centralized around family physicians that play a role as gatekeepers. Secondary care is mainly provided in hospitals. These hospitals have both inpatient and outpatient services. The 9 university hospitals, regionally distributed, play a role as “leading” hospitals for specialist medical interventions. In the 1990’s measures were taken to bridge the (organizational and financing) gap between outpatient and inpatient care, by means of “transmural” (integrated) care: a mechanism to coordinate and organise continuity of care for the patients. These initiatives developed as “projects”, most of the time focused on specific groups of chronic patients, with intermittent acute care needs. However, the financing system did not facilitate an easy implementation of a smoothly functioning transmural (or integrated) care system. The most important part of residential social services consists of nursing homes and homes for the elderly. Residential homes are particularly established for those people who are not able or feel unsafe to live independently at home. A distinction has to be made between somatic nursing homes (disabled people needing multidisciplinary monitoring and treatment) and psycho-geriatric nursing homes (for people with dementia). Admissions to residential care have decreased in the last years, because of transmural initiatives (e.g. day care centres) on the care side and improvement of availability of home care services. The hospitals were financed through a fixed budget system. The problems with waiting lists culminated in 1997 in measures making additional money available to reduce unacceptable waiting times. In 2005 a new hospital financing system was introduced by law: the “diagnosistreatment-combination” (Diagnose Behandel Combinaties (DBCs)), a DRG-like system describing all products and procedures provided in hospitals. z DBCs are defined as the whole set of activities (diagnostic and therapeutic interventions) of the hospital and medical specialists from start till discharge, using the ICD-10 classification. A patient can z http://www.minvws.nl/dossiers/dbc/
KCE reports 57 Musculoskeletal & Neurological Rehabilitation 155 enter in a DBC-trajectory by referral of his general practitioner (GP) or a medical specialist. The introduction of the DBC financing model goes hand in hand with an extended registration system. A DBC treatment trajectory can take one day up to one year. A treatment trajectory is ended at the end of the year, in case the treatment is stopped or in case a patient starts a different dbc (e.g. the inpatient trajectory is stopped when the patient starts an ambulatory treatment; an ambulatory trajectory is then started). DBCs distinguish between list A (prices fixed by the National Health Tariffs authority) and list B (an fixed part and a part of the prices negotiated by Sickness Funds and hospitals). DBC’s are used as a framework for price negotiations between health insurers and hospitals. Agencies were created to manage the implementation and follow up of the DBC financing model aa Congruent with a market driven approach, major efforts are now being put into the development of performance indicators. These performance indicators are mainly seen as a quality tool, and a facility for consumers to support informed choices on the health care market. The development of these performance indicators is still in an early stage, although a lot of debates are taking place on the conceptual level. • The Dutch health care system is characterized by territorial decentralisation. • A market-driven approach has been introduced (purchaser-provider). • Integration of care and networking of health care organisations is stimulated. • The “Ziekteverzekeringswet” insures for medical expenses. • The AWBZ used to insure for exceptional medical expenses and long term care. • The financing of medical activities in hospitals is based on “Diagnose Behandel Combinaties”, and is performance related. Extensive registration is set up. 8.3.3 The organization of the rehabilitation sector (See also Appendix to chapter 8 (1.8.2.2)) 8.3.3.1 The underlying conceptual ideas The Dutch rehabilitation “logic” differentiates between different levels on a continuum from “general and simple” toward “specialised and specific”. In conceptual terms a differentiation is made between (a) simple rehabilitation (b) general multidisciplinary rehabilitation (c) specialized target (pathology) group oriented multidisciplinary rehabilitation and (d) highly specialized rehabilitation (“topreferente”). bb For relatively “simple” rehabilitation a referral is needed from the medical specialist to the physical therapist. In the case of complex issues, a medical rehabilitation specialist becomes in charge of the patient. A “complex” situation is generally assessed as a medical condition in which the risk of long term impairment or handicap is real. For specific cases the rehabilitation physician will mobilize a multidisciplinary team in case of discharge of the patient to a home setting. aa http://www.dbconderhoud.nl/ bb http://www.revalidatie.nl/index_3.htm
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Dépôt légal : D/2007/10.273/19
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