What is the actual functioning of the health market now?

It's a defining moment. Health market forces are again under discussion due to the bankruptcy of two private hospitals. And just this Monday, a lawsuit in Arnhem addresses the fundamentals of this market operation.

On the one hand, the Foundation for the Application of Free Choice of Physicians, which acts on behalf of more than 30 private health care providers, such as private clinics, health facilities mental therapists, physiotherapists and district nurses. They argue in court that the patient can choose his treatment providers and that this treatment is (almost) fully reimbursed at a competitive rate.

The forces of the health market are in their eyes: the free choice of the care provider for all patients. It does not matter if these patients have a policy in kind or a refund policy.

On the other side are the major health insurers. They often spend up to 75%, and sometimes even less, on patient care provided by these "non-contracted" health care providers. The rest must be paid for by the patient himself, otherwise the care provider must not let him go leniently.

For insurers, the health care system put in place in 2006 is based precisely on their role as a scarecrow. On behalf of the insured, they need strong bargaining power to control the cost of care. The insured person has little to negotiate with a hospital or other health facility. Insurers can do this by contracting with health care providers. In this sense, they conclude agreements on the best quality and especially the best price of the care provided. Otherwise, everyone can simply ask what he wants and the costs of care will be lost.

What is the importance of insurers to find this lawsuit? Very important The Foundation for the Application of Free Choice of Doctors has convened VGZ and Menzis. Zilveren Kruis and CZ, who consider that the case is very principled, have "joined". Together, these four leading health insurers have a 88% market share.

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Health Care Providers

It is not patients who plead in court Monday to enjoy full freedom of choice, but private health care providers. For them, market forces mean space for a free entrepreneur. There, they are now limited by health insurers, because they do not fully refund their treatments. Patients stay away if they have to pay a quarter or more themselves, in addition to their own risks.

Some health care providers themselves occupy this so-called exit. For example, the ophthalmological clinic Drechtsteden, which performs laser treatments. Director Martin Struijk: "We scolded this out because the patient would otherwise stay out of the way, we are providing care as good as in the hospitals, and that's where we, the four ophthalmologists, have seen waiting lists to lengthen. "However, according to Struijk, the discounts currently made" lead to prices that are no longer realistic "

Why there is no contract with health insurers ? "We are still young and need growth to function effectively, but health insurers want to hear about ceilings for the number of treatments, which limits this growth."

Struijk doubts the way in which health insurers calculate the reimbursement of the treatments of his ophthalmic clinic. The exit, the 25% not reimbursed, is not calculated on the rate charged by his clinic. The discounts are made on rates that no one can understand, with the exception of the health insurers themselves. "Some of them set this very low average, so that's no longer possible for us, I know that hospitals usually charge between 900 and 1100 euros for a cataract surgery, but it's not that we receive 75%. "

Discounts can be large amounts per patient. An institution specializing in mental health care that, like some others, does not want to be named for fear of reprisals from insurers, carries out treatments that can cost 10,000 euros per patient. Insurers pay between 6,000 and 7,000 euros. But vulnerable patients with often little money than asking for 3,000 or 4,000 euros, the institution goes too far. She makes the difference on her own. "This is no longer tenable," said one of the directors.

Kim Lieuwen, director of a drug treatment facility in Apeldoorn, has deliberately not contracted with insurers. "But then you have to deal with all sorts of inconveniences: conditions, late payments, waiting six weeks for approval of treatments, then low rates.Although I comply with the rates set by the Dutch Health Authority I receive between 55 and 72% of this amount, according to the insurer.I can not ask addicts this difference, for treatments up to 40 000. But self-assignment can not not to be maintained. "

The director of a relatively young rehabilitation center threatened to obtain higher rates. In order to prevent a process, health insurers offered contracts, although at 75% of rates. The director agreed. Certainly, he explains, "the way insurers calculate market-based rates" is completely opaque, but it saves him a lot of paperwork on the grounds that he was accused of not having contracted.

But it also faces budget ceilings. And it's a problem because it wants to form a larger whole with parties that do not keep it now. "We are doing well, we are getting good evaluations of the measurements among patients, and we do not have long waiting times, like providers who have been dealing with insurers for a long time. growth. "

A nationwide clinic had a contract with a major insurer, but terminated it. "We receive referrals from GPs across the country, we do not want to deny patients, so we have exceeded the agreed treatment ceiling and we had to pay the excess back to the health insurer," says the director. .

His clinic also faces the opacity of "market compliance" rates with which insurers rely. Based on his own research on the rates charged in competing hospitals and on the data of the health care provider NZA, he concluded that the fee for a treatment such as that of his clinic is about 1,600 euros. "If you know we only get a competitive price of 800 euros, it's very unpleasant."

Hinderpaal

What are market-based tariffs? This has been the central issue since the Supreme Court in 2014 stipulated that insurers must also pay for non-contracted care providers, so there is nothing to prevent them from using such a party. . Although the highest court has not drawn a clear dividing line, health insurers have since paid at least 75% of the average rate. According to them, there is therefore no "obstacle" for patients to choose their own doctor, and Article 13 of the Dutch Health Insurance Act is respected.

The main point is that the 13th article dates from Monday around. It states that an insured person is entitled to reimbursement for health care, even if he buys them from a provider who does not have a contract with his health insurer. When the law was passed by the Dutch Parliament, it was declared in the lower house that the insurer should put no obstacle in this regard.

It is multi-interpretable. In recent years, several health care providers have sued health insurers for higher rates. They won many of these cases, partly because of the Supreme Court ruling. But this judgment did not give a precise limit; However, the board limited the reduction by stipulating that the insurer could only charge an administrative fee.

This allowed health care providers to progress. But it soon became clear that they were not able to determine the competitive rate. Health insurers invoke confidentiality statements in their contracts, they noted

. On the other hand, these health care insurers are not satisfied with this strict rule of 75%. They want an instrument to make sure that non-insured people they do not see are also unattractive to their policyholders.

Also read this story of 2016: Ten Years of New Health Care System: This Resulted in the Creation of [19659008] Health Care Insurers

In granting the claims of the Foundation, the Health care insurers recognize the role of the director they consider responsible when the new health care system will end in 2006. "One of the pillars of this system is precisely the conclusion of contracts with health care providers of health, "said Maaike Verkooijen, VGZ Policy Coordinator. "But if the foundation is correct, then an important reason for contracting with health care providers will expire and they will be able to ask what they want." Joas Duister, executive secretary of Menzis, also said that "the role of insurers' purchase is played" if we but the administrative costs may be charged. "

Insurers consider that their role is to select the highest quality care providers for their millions of insureds and to agree on actual prices." But why would health care providers always spend contracts with us if we are forced to pay in full? "How can we manage quality, affordability and innovation?" said Duister.

Insurers deny being deceived with average rates. A few years ago, they admitted that the situation was not clear, at least at the prices of hospitals. But they carried great blows. "It's more than these rates are so diverse and there are unexplained differences.Since 2016, when there has been a lot of noise, the situation has changed.The situation is quieter, you see little outlier data "said Duister.

On Monday, insurers will present figures showing that non-contracted care in VGZ and Menzis doubled in 2016 and the following year. doubled, they want to make it clear that entry into the market is not really difficult and that research shows that the cost per insured person for non-contracted care is twice as high as for contract care. they charge higher prices because they provide more hours of care than contractors, which is not explained by the health of patients, "says Verkooijen of VGZ.

New entrants do not do not they grow quickly? " Outreach also began a few years ago as a newcomer and they now have big contracts, "said Duister.

A catastrophic scenario if they say the health care system becomes unaffordable if they have to pay higher reimbursements to non-contracted health care providers? No, say health insurers.

Yes, says SHVA Lawyer Koen Mous points out that the non-outsourced segment is relatively small, with about 1% of the total turnover of health care within the meaning of the Health Care Insurance Act. "There is a lot to be said about the described disaster scenario," he says. health can ask what they want, it's really nonsense. We believe that the balance of power in the market will be restored if the demands of the Foundation are awarded. The real price negotiations are now barely taking place, as health insurance companies enter into budget agreements and then allocate prices to health products in rather random ways. Care providers without a contract are paid on the basis of these unrealistic prices, which are also reduced by at least 25%. Health insurers should pay more attention to contracts based on quality and innovation. The stimulation of competition instead of rucksichtslos a reduction in tariffs will have a favorable effect on total costs. "

It is striking that VGZ and Menzis say that they will not report a risk of fraud, as it was this year, insured by the health insurers, nor is it illogical because insurers themselves show that the fraud is committed annually for around 30 million euros. "A fraction of the total health expenditure of 96 billion euros in the Netherlands," explains Mous, "and this also implies subcontractors "

The insurers made this choice consciously, they say Maaike Verkooijen:" Our position is that the contracts are positive. Not based on mistrust, but on joint agreements. Contracts focus on continuity, cost and quality of care to make them accessible and affordable. "