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34 APPENDICES Physiotherapy KCE reports vol. 40 These data will be the basis for a general, compulsory, computerised system of data registration for physiotherapy (EGF: Elektronische Fysiotherapeutische Verslaglegging). This project is presently in a pilot phase. This standardised reporting has, on the one hand, a clinical objective (helping the physiotherapist in its practice), and a monitoring objective at a higher level (for instance, documenting adherence to guidelines). It should complement, not duplicate, data provided by the sentinel network. 5.8. UTILISATION OF ICF AND FINANCING: THE AMSTERDAM MODEL At the time the Amsterdams dienstenmodel was proposed (1997), both private and public health insurers in Holland were refunding only 9 sessions of physiotherapy per year and per problem (except for those patients suffering from a chronic disease in the list ). The Amsterdams dienstenmodel proposed an alternative to this rigid, one-size-fits-all rule, by devising 11 different categories of entitlements, from one session (diagnosis) to more than 30 sessions per year (see annex). These categories, or products , to use insurance terminology, were not defined on the basis of a medical diagnosis (like the lists F or S in Belgium), but rather took into account the patient complaint and the physiotherapist assessment of the objectives of treatment. The Amsterdams dienstenmodel made use of ICF concepts - (not of ICF codes or definitions) in linking treatment objectives to a certain number of sessions. If the main objective was to improve functioning , then the patient was entitled to a short treatment (10 sessions over 12 weeks). If the main objective was to improve activities, then the entitlement was to 20 sessions over 6 months. If the objective was to improve participation, then the entitlement was to a long treatment 30 sessions per year. This model was developed by health insurer ZAO ( Ziekenfonds Amsterdam en Omstreken ) together with regional professional associations of physiotherapists, and piloted in Amsterdam. A first evaluation showed that this model cost no more that the 9-sessions scheme, but entailed higher patients and providers satisfaction. Based on the medical diagnosis, paramedical diagnosis and treatment objectives, the therapist would choose the most suitable subservice. Therapists could switch to an alternative subservice provided they informed the referring practitioners. In case the anticipated maximum is exceeded, a report should be filed with ZAO containing a detailed description of needed care. Finally, patients can recurrently be referred for the same indication within the same year. When regional insurers ZAO, Anoz and Anova merged into nationwide insurer Agis it was decided not to upscale the Amsterdams Dienstenmodel. As general practitioners and paramedical therapists outside of the wider Amsterdam region were unfamiliar with (the principles underlying) the Amsterdams Dienstenmodel, a potential nationwide extension of the model was curbed. Moreover, the application of the model was discontinued in the Amsterdam region. Since then coverage of physiotherapy within the public and/or compulsory insurance system has been dramatically reduced. The Amsterdam model proposed at that time an alternative to a system that no longer exists today in the Netherlands.
KCE reports vol.40 APPENDICES Physiotherapy 35 5.9. CONCLUSIONS - KEY POINTS Coverage for physiotherapy in primary care in the Netherlands under the compulsory insurance scheme is extremely limited (chronic diseases, children); 90-95% of the population has a voluntary health insurance, for which different schemes exist. Private health insurers are key actors in physiotherapy, ambulatory care. They contract and monitor the providers; the terms of the voluntary insurance contract determine the amount of physiotherapy services that could be claimed by the insured person in a year. The trend among health insurers is towards the definition of products a package of care, for a given condition. However very little yet exists for physiotherapy. Coverage for physiotherapy services is usually expressed as a maximum number of physiotherapy sessions, or a cost ceiling, and does not depend on the condition. A project using ICF concepts in product definition (different number of sessions being refunded if the objective is to improve functioning, activities, or participation) was not extended over its pilot phase The Netherlands have extensive experience in quality insurance for physiotherapy. Continuing education and peer group meeting are central elements of this system. A project for a general, electronic, standardised, compulsory reporting in its pilot phase A sentinel system allows the collection of routine data on an ongoing basis; these data are used to monitor trends such as the use of guidelines, or the impact of reforms.
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